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Case Studies

More than 70 cases pair ethics concepts with real world situations. From journalism, performing arts, and scientific research to sports, law, and business, these case studies explore current and historic ethical dilemmas, their motivating biases, and their consequences. Each case includes discussion questions, related videos, and a bibliography.

A Million Little Pieces

James Frey’s popular memoir stirred controversy and media attention after it was revealed to contain numerous exaggerations and fabrications.

Abramoff: Lobbying Congress

Super-lobbyist Abramoff was caught in a scheme to lobby against his own clients. Was a corrupt individual or a corrupt system – or both – to blame?

Apple Suppliers & Labor Practices

Is tech company Apple, Inc. ethically obligated to oversee the questionable working conditions of other companies further down their supply chain?

Approaching the Presidency: Roosevelt & Taft

Some presidents view their responsibilities in strictly legal terms, others according to duty. Roosevelt and Taft took two extreme approaches.

Appropriating “Hope”

Fairey’s portrait of Barack Obama raised debate over the extent to which an artist can use and modify another’s artistic work, yet still call it one’s own.

Arctic Offshore Drilling

Competing groups frame the debate over oil drilling off Alaska’s coast in varying ways depending on their environmental and economic interests.

Banning Burkas: Freedom or Discrimination?

The French law banning women from wearing burkas in public sparked debate about discrimination and freedom of religion.

Birthing Vaccine Skepticism

Wakefield published an article riddled with inaccuracies and conflicts of interest that created significant vaccine hesitancy regarding the MMR vaccine.

Blurred Lines of Copyright

Marvin Gaye’s Estate won a lawsuit against Robin Thicke and Pharrell Williams for the hit song “Blurred Lines,” which had a similar feel to one of his songs.

Bullfighting: Art or Not?

Bullfighting has been a prominent cultural and artistic event for centuries, but in recent decades it has faced increasing criticism for animal rights’ abuse.

Buying Green: Consumer Behavior

Do purchasing green products, such as organic foods and electric cars, give consumers the moral license to indulge in unethical behavior?

Cadavers in Car Safety Research

Engineers at Heidelberg University insist that the use of human cadavers in car safety research is ethical because their research can save lives.

Cardinals’ Computer Hacking

St. Louis Cardinals scouting director Chris Correa hacked into the Houston Astros’ webmail system, leading to legal repercussions and a lifetime ban from MLB.

Cheating: Atlanta’s School Scandal

Teachers and administrators at Parks Middle School adjust struggling students’ test scores in an effort to save their school from closure.

Cheating: Sign-Stealing in MLB

The Houston Astros’ sign-stealing scheme rocked the baseball world, leading to a game-changing MLB investigation and fallout.

Cheating: UNC’s Academic Fraud

UNC’s academic fraud scandal uncovered an 18-year scheme of unchecked coursework and fraudulent classes that enabled student-athletes to play sports.

Cheney v. U.S. District Court

A controversial case focuses on Justice Scalia’s personal friendship with Vice President Cheney and the possible conflict of interest it poses to the case.

Christina Fallin: “Appropriate Culturation?”

After Fallin posted a picture of herself wearing a Plain’s headdress on social media, uproar emerged over cultural appropriation and Fallin’s intentions.

Climate Change & the Paris Deal

While climate change poses many abstract problems, the actions (or inactions) of today’s populations will have tangible effects on future generations.

Cover-Up on Campus

While the Baylor University football team was winning on the field, university officials failed to take action when allegations of sexual assault by student athletes emerged.

Covering Female Athletes

Sports Illustrated stirs controversy when their cover photo of an Olympic skier seems to focus more on her physical appearance than her athletic abilities.

Covering Yourself? Journalists and the Bowl Championship

Can news outlets covering the Bowl Championship Series fairly report sports news if their own polls were used to create the news?

Cyber Harassment

After a student defames a middle school teacher on social media, the teacher confronts the student in class and posts a video of the confrontation online.

Defending Freedom of Tweets?

Running back Rashard Mendenhall receives backlash from fans after criticizing the celebration of the assassination of Osama Bin Laden in a tweet.

Dennis Kozlowski: Living Large

Dennis Kozlowski was an effective leader for Tyco in his first few years as CEO, but eventually faced criminal charges over his use of company assets.

Digital Downloads

File-sharing program Napster sparked debate over the legal and ethical dimensions of downloading unauthorized copies of copyrighted music.

Dr. V’s Magical Putter

Journalist Caleb Hannan outed Dr. V as a trans woman, sparking debate over the ethics of Hannan’s reporting, as well its role in Dr. V’s suicide.

East Germany’s Doping Machine

From 1968 to the late 1980s, East Germany (GDR) doped some 9,000 athletes to gain success in international athletic competitions despite being aware of the unfortunate side effects.

Ebola & American Intervention

Did the dispatch of U.S. military units to Liberia to aid in humanitarian relief during the Ebola epidemic help or hinder the process?

Edward Snowden: Traitor or Hero?

Was Edward Snowden’s release of confidential government documents ethically justifiable?

Ethical Pitfalls in Action

Why do good people do bad things? Behavioral ethics is the science of moral decision-making, which explores why and how people make the ethical (and unethical) decisions that they do.

Ethical Use of Home DNA Testing

The rising popularity of at-home DNA testing kits raises questions about privacy and consumer rights.

Flying the Confederate Flag

A heated debate ensues over whether or not the Confederate flag should be removed from the South Carolina State House grounds.

Freedom of Speech on Campus

In the wake of racially motivated offenses, student protests sparked debate over the roles of free speech, deliberation, and tolerance on campus.

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?

Full Disclosure: Manipulating Donors

When an intern witnesses a donor making a large gift to a non-profit organization under misleading circumstances, she struggles with what to do.

Gaming the System: The VA Scandal

The Veterans Administration’s incentives were meant to spur more efficient and productive healthcare, but not all administrators complied as intended.

German Police Battalion 101

During the Holocaust, ordinary Germans became willing killers even though they could have opted out from murdering their Jewish neighbors.

Head Injuries & American Football

Many studies have linked traumatic brain injuries and related conditions to American football, creating controversy around the safety of the sport.

Head Injuries & the NFL

American football is a rough and dangerous game and its impact on the players’ brain health has sparked a hotly contested debate.

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.

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.

In-FUR-mercials: Advertising & Adoption

When the Lied Animal Shelter faces a spike in animal intake, an advertising agency uses its moral imagination to increase pet adoptions.

Krogh & the Watergate Scandal

Egil Krogh was a young lawyer working for the Nixon Administration whose ethics faded from view when asked to play a part in the Watergate break-in.

Limbaugh on Drug Addiction

Radio talk show host Rush Limbaugh argued that drug abuse was a choice, not a disease. He later became addicted to painkillers.

U.S. Olympic swimmer Ryan Lochte’s “over-exaggeration” of an incident at the 2016 Rio Olympics led to very real consequences.

Meet Me at Starbucks

Two black men were arrested after an employee called the police on them, prompting Starbucks to implement “racial-bias” training across all its stores.

Myanmar Amber

Buying amber could potentially fund an ethnic civil war, but refraining allows collectors to acquire important specimens that could be used for research.

Negotiating Bankruptcy

Bankruptcy lawyer Gellene successfully represented a mining company during a major reorganization, but failed to disclose potential conflicts of interest.

Pao & Gender Bias

Ellen Pao stirred debate in the venture capital and tech industries when she filed a lawsuit against her employer on grounds of gender discrimination.

Pardoning Nixon

One month after Richard Nixon resigned from the presidency, Gerald Ford made the controversial decision to issue Nixon a full pardon.

Patient Autonomy & Informed Consent

Nursing staff and family members struggle with informed consent when taking care of a patient who has been deemed legally incompetent.

Prenatal Diagnosis & Parental Choice

Debate has emerged over the ethics of prenatal diagnosis and reproductive freedom in instances where testing has revealed genetic abnormalities.

Reporting on Robin Williams

After Robin Williams took his own life, news media covered the story in great detail, leading many to argue that such reporting violated the family’s privacy.

Responding to Child Migration

An influx of children migrants posed logistical and ethical dilemmas for U.S. authorities while intensifying ongoing debate about immigration.

Retracting Research: The Case of Chandok v. Klessig

A researcher makes the difficult decision to retract a published, peer-reviewed article after the original research results cannot be reproduced.

Sacking Social Media in College Sports

In the wake of questionable social media use by college athletes, the head coach at University of South Carolina bans his players from using Twitter.

Selling Enron

Following the deregulation of electricity markets in California, private energy company Enron profited greatly, but at a dire cost.

Snyder v. Phelps

Freedom of speech was put on trial in a case involving the Westboro Baptist Church and their protesting at the funeral of U.S. Marine Matthew Snyder.

Something Fishy at the Paralympics

Rampant cheating has plagued the Paralympics over the years, compromising the credibility and sportsmanship of Paralympian athletes.

Sports Blogs: The Wild West of Sports Journalism?

Deadspin pays an anonymous source for information related to NFL star Brett Favre, sparking debate over the ethics of “checkbook journalism.”

Stangl & the Holocaust

Franz Stangl was the most effective Nazi administrator in Poland, killing nearly one million Jews at Treblinka, but he claimed he was simply following orders.

Teaching Blackface: A Lesson on Stereotypes

A teacher was put on leave for showing a blackface video during a lesson on racial segregation, sparking discussion over how to teach about stereotypes.

The Astros’ Sign-Stealing Scandal

The Houston Astros rode a wave of success, culminating in a World Series win, but it all came crashing down when their sign-stealing scheme was revealed.

The Central Park Five

Despite the indisputable and overwhelming evidence of the innocence of the Central Park Five, some involved in the case refuse to believe it.

The CIA Leak

Legal and political fallout follows from the leak of classified information that led to the identification of CIA agent Valerie Plame.

The Collapse of Barings Bank

When faced with growing losses, investment banker Nick Leeson took big risks in an attempt to get out from under the losses. He lost.

The Costco Model

How can companies promote positive treatment of employees and benefit from leading with the best practices? Costco offers a model.

The FBI & Apple Security vs. Privacy

How can tech companies and government organizations strike a balance between maintaining national security and protecting user privacy?

The Miss Saigon Controversy

When a white actor was cast for the half-French, half-Vietnamese character in the Broadway production of Miss Saigon , debate ensued.

The Sandusky Scandal

Following the conviction of assistant coach Jerry Sandusky for sexual abuse, debate continues on how much university officials and head coach Joe Paterno knew of the crimes.

The Varsity Blues Scandal

A college admissions prep advisor told wealthy parents that while there were front doors into universities and back doors, he had created a side door that was worth exploring.

Providing radiation therapy to cancer patients, Therac-25 had malfunctions that resulted in 6 deaths. Who is accountable when technology causes harm?

Welfare Reform

The Welfare Reform Act changed how welfare operated, intensifying debate over the government’s role in supporting the poor through direct aid.

Wells Fargo and Moral Emotions

In a settlement with regulators, Wells Fargo Bank admitted that it had created as many as two million accounts for customers without their permission.

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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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• 26 Mar 2024
• Cold Call Podcast

How Do Great Leaders Overcome Adversity?

In the spring of 2021, Raymond Jefferson (MBA 2000) applied for a job in President Joseph Biden’s administration. Ten years earlier, false allegations were used to force him to resign from his prior US government position as assistant secretary of labor for veterans’ employment and training in the Department of Labor. Two employees had accused him of ethical violations in hiring and procurement decisions, including pressuring subordinates into extending contracts to his alleged personal associates. The Deputy Secretary of Labor gave Jefferson four hours to resign or be terminated. Jefferson filed a federal lawsuit against the US government to clear his name, which he pursued for eight years at the expense of his entire life savings. Why, after such a traumatic and debilitating experience, would Jefferson want to pursue a career in government again? Harvard Business School Senior Lecturer Anthony Mayo explores Jefferson’s personal and professional journey from upstate New York to West Point to the Obama administration, how he faced adversity at several junctures in his life, and how resilience and vulnerability shaped his leadership style in the case, "Raymond Jefferson: Trial by Fire."

• 02 Jan 2024

Should Businesses Take a Stand on Societal Issues?

Should businesses take a stand for or against particular societal issues? And how should leaders determine when and how to engage on these sensitive matters? Harvard Business School Senior Lecturer Hubert Joly, who led the electronics retailer Best Buy for almost a decade, discusses examples of corporate leaders who had to determine whether and how to engage with humanitarian crises, geopolitical conflict, racial justice, climate change, and more in the case, “Deciding When to Engage on Societal Issues.”

• 12 Dec 2023

Can Sustainability Drive Innovation at Ferrari?

When Ferrari, the Italian luxury sports car manufacturer, committed to achieving carbon neutrality and to electrifying a large part of its car fleet, investors and employees applauded the new strategy. But among the company’s suppliers, the reaction was mixed. Many were nervous about how this shift would affect their bottom lines. Professor Raffaella Sadun and Ferrari CEO Benedetto Vigna discuss how Ferrari collaborated with suppliers to work toward achieving the company’s goal. They also explore how sustainability can be a catalyst for innovation in the case, “Ferrari: Shifting to Carbon Neutrality.” This episode was recorded live December 4, 2023 in front of a remote studio audience in the Live Online Classroom at Harvard Business School.

• 11 Dec 2023
• Research & Ideas

Doing Well by Doing Good? One Industry’s Struggle to Balance Values and Profits

Few companies wrestle with their moral mission and financial goals like those in journalism. Research by Lakshmi Ramarajan explores how a disrupted industry upholds its values even as the bottom line is at stake.

• 27 Nov 2023

Voting Democrat or Republican? The Critical Childhood Influence That's Tough to Shake

Candidates might fixate on red, blue, or swing states, but the neighborhoods where voters spend their teen years play a key role in shaping their political outlook, says research by Vincent Pons. What do the findings mean for the upcoming US elections?

• 21 Nov 2023

The Beauty Industry: Products for a Healthy Glow or a Compact for Harm?

Many cosmetics and skincare companies present an image of social consciousness and transformative potential, while profiting from insecurity and excluding broad swaths of people. Geoffrey Jones examines the unsightly reality of the beauty industry.

• 09 Nov 2023

What Will It Take to Confront the Invisible Mental Health Crisis in Business?

The pressure to do more, to be more, is fueling its own silent epidemic. Lauren Cohen discusses the common misperceptions that get in the way of supporting employees' well-being, drawing on case studies about people who have been deeply affected by mental illness.

• 07 Nov 2023

How Should Meta Be Governed for the Good of Society?

Julie Owono is executive director of Internet Sans Frontières and a member of the Oversight Board, an outside entity with the authority to make binding decisions on tricky moderation questions for Meta’s companies, including Facebook and Instagram. Harvard Business School visiting professor Jesse Shapiro and Owono break down how the Board governs Meta’s social and political power to ensure that it’s used responsibly, and discuss the Board’s impact, as an alternative to government regulation, in the case, “Independent Governance of Meta’s Social Spaces: The Oversight Board.”

• 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.

• 29 Nov 2022

How Will Gamers and Investors Respond to Microsoft’s Acquisition of Activision Blizzard?

In January 2022, Microsoft announced its acquisition of the video game company Activision Blizzard for $68.7 billion. The deal would make Microsoft the world’s third largest video game company, but it also exposes the company to several risks. First, the all-cash deal would require Microsoft to use a large portion of its cash reserves. Second, the acquisition was announced as Activision Blizzard faced gender pay disparity and sexual harassment allegations. That opened Microsoft up to potential reputational damage, employee turnover, and lost sales. Do the potential benefits of the acquisition outweigh the risks for Microsoft and its shareholders? Harvard Business School associate professor Joseph Pacelli discusses the ongoing controversies around the merger and how gamers and investors have responded in the case, “Call of Fiduciary Duty: Microsoft Acquires Activision Blizzard.”

• 15 Nov 2022

Stop Ignoring Bad Behavior: 6 Tips for Better Ethics at Work

People routinely overlook wrongdoing, even in situations that cause significant harm. In his book Complicit: How We Enable the Unethical and How to Stop, Max Bazerman shares strategies that help people do the right thing even when those around them aren't.

• 08 Nov 2022

How Centuries of Restrictions on Women Shed Light on Today's Abortion Debate

Going back to pre-industrial times, efforts to limit women's sexuality have had a simple motive: to keep them faithful to their spouses. Research by Anke Becker looks at the deep roots of these restrictions and their economic implications.

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A discussion around the use of cases in teaching RCR, part of the  Instructor's Guide to Prepare Research Group Leaders as RCR Mentors .

NOTES TO THE INSTRUCTOR:

• You should feel free to choose your own case for this section, or choose several, giving each small group a distinct case to discuss. Given the time constraints of both this workshop and most lab meetings, it would be best for the cases to be relatively uncomplicated, though still nuanced.
• While this curriculum provides a basic case analysis scheme, if you use case analyses regularly, you likely know there are several ways of analyzing cases, and many frameworks out there to assist your students, depending on how you use / what you want the students to learn from using the cases. Some of those are included in the resources section of this curriculum; you could provide a couple of different evaluation schemas to determine if one is more appropriate for a particular discipline, or career stage, than another.
• If you’re using an agenda which includes an over‐lunch discussion of a case, as the agenda in this instructor’s manual shows, we used the 15 minute window just before lunch to go over the case studies section of the syllabus, coming back to the question “How might cases be introduced into the research environment?” in the after‐lunch discussion.
• It is important that the larger group discussion about the case(s) not become simply a discussion of the case per se, but that it also include a conversation about how useful this kind of discussion can be with their students. We found that our groups were eager to discuss the elements of the case, but we had to explicitly articulate the usefulness of such case discussions as tools for integrating ethics into their research environments.
• You might also ask your workshop participants if other kinds of “cases” – those drawn from current events, for instance, or those written as “two minute challenges” [https://nationalethicscenter.org/resources/146/download/2MC%20methodology.pdf] – might also work in the research environment.
• One of the evaluators of an earlier version of the curriculum noted that these workshops “could include tips on how to identify and choose in‐the‐news cases, challenges in discussing them, and bringing closure to such discussions. Of course an in‐the‐news case discussion would be modeled in the workshop as well. Alternatively, the workshop could promote the idea of providing case study (either created or found) discussion in a context similar to a journal club, or even as an occasional event in existing journal clubs.” This underscores the idea we had when creating this curriculum that all of those venues are considered “the research environment.”

What are case studies?

Based on real or contrived scenarios, case studies 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 researchers 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.

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 various options for resolution. In addition to the specific questions accompanying some cases, an effective analysis will typically address the following criteria:

Who is affected (individuals, institutions, a field, society)? What significant interest(s) (material, financial, ethical, other) do those affected have in the situation? Which interests are in conflict ?

What specific, generalizable, and consistent principles (e.g., to tell the truth, to do no harm) are applicable to this case?

• Alternate answers

What other courses of action are open to each of those affected? What is the likely outcome of each course of action? What actions could have been taken to avoid the conflict?

Are the final choice and its consequences defensible in public (e.g., reported through the media)? 

Is there a right answer?

• Acceptable Solutions:

Most problems will have several acceptable solutions or answers, but a single perfect solution often cannot be found. At times, even the best solution will have 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, regulations, or 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:

Ethical decision-making is a process rather than an outcome. The clearest instance of a wrong answer is the failure to engage in that process. Not trying to define a consistent and defensible basis for decisions or conduct is unacceptable.

How might cases be introduced into the research environment?

Cases are best seen as an opportunity to foster discussion among several individuals. As such, they might be most appropriate as an exercise to be used in the context of a research group meeting, journal club, or as part of a research lecture series.

During the lunch break, workshop participants will be assigned to small groups for the purpose of reviewing a case (scenario) describing a research ethics challenge. Ideally discussion group participants should be from diverse disciplines and people who do not already know one another well. This will increase the chance to better see challenges and find solutions for the case being reviewed. It also hopefully serves to increase personal connections among diverse members of the institution who can turn to one another with future ethics and ethics training questions or challenges.

Case for Discussion

How much is too much?

Qiao Zhi has recently arrived to work as a postdoctoral research in the United States from China. She studied English for many years as part of her schooling in China, but she had little real world experience in conversing and writing English. Qiao Zhi is a very talented scientist in her field and quickly found a position in a research group, largely consisting of other Chinese researchers and with Professor Wang, who was trained in China as well. During her first year of work, Qiao Zhi was extraordinarily lucky to have made an interesting finding and Professor Wang encouraged her to write the work up for publication in the journal Science. Qiao Zhi struggled to write the paper in English, but soon found that with the help of the Internet she could easily find phrases written well in English to express concepts that she wasn't sure of. Professor Wang lightly edited the paper written by Qiao Zhi, they submitted it to Science, and it was accepted for publication. Six months later, one of Wang's colleagues was looking at the Déjà vu website (http://dejavu.vbi.vt.edu/dejavu) and discovered that Qiao Zhi's paper received a very high score for using text duplicated from other papers. Wang took the concern of possible plagiarism to the Research Integrity Officer (RIO) at his institution. The RIO appointed a committee to determine if Qiao Zhi should be found guilty of plagiarism, an example of research misconduct. You are a member of that committee and have been asked to decide whether frequent use of phrases from other papers is plagiarism and if doing so should result in sanctions or penalties.

Recommended timetable:

During lunch:

• Introductions (5 mins):

Introduce yourselves to one another, pick someone to serve as discussion leader (responsible for keeping discussion on track and on time), and someone to keep a written summary of key conclusions. If not all members of the group have already been introduced to the case, the group leader should read the case aloud.

• Case Discussion (20 mins):

Collectively consider the (1) interests of individuals and groups in how this case is handled; (2) ethical principles or values at stake; (3) the alternative answers that might be considered as solutions; and (4) the rationales for selecting a particular choice of action agreeable to all.

• Summary (10 mins):

As a group, figure out how best to articulate your findings of interests and principles that are at stake, the alternative answers to be considered, your recommended answer, and the rationale for choosing that answer.

After lunch

• Presentation (~ variable)

Choose one member of your group to present your analysis, paying attention not just to the case per se, but also how this kind of exercise could be beneficial for your trainees.

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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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The Case of Joe

The Case of Joe: Ethical End of Life Decisions

“Give me something. I want to die.”

“Joe” is a 62-year-old building contractor who has been in an ICU for the past 10 weeks. He had gone to his community hospital for bypass surgery (CABG) and aortic valve repair (AVR), and things didn’t go well post-op. His sternal wound became infected with Methicillin-resistant Staphylococcus Aureus (MRSA). Sepsis led to acute hypoxic respiratory failure, a tracheotomy, profound hearing loss, and then acute renal failure ameliorated somewhat by hemodialysis.

The complexity and severity of Joe’s post-operative condition has resulted in transfer to our larger tertiary facility for the past 6 weeks. He now has been weaned off the vent to a few hours of room air, but the care team is not as optimistic as Joe’s family remains. Per chart notes, he is not improving sufficiently to warrant hope for recovery. The best that can be hoped for now, says his critical care physician, is discharge to a long-term acute care hospital (L-TACH). The prognosis does not include any likelihood of return to baseline, or to home. The situation is dire, and Joe seems to “get it.”

On the Saturday of Joe’s tenth week in ICU, he mouths a message to his nurse, and then to the physician who is summoned, and then to an ethics consultant also. “Stop everything. Give me something. I want to die.”

Joe repeats his request with family at the bedside. In later conversation with the ethics consultant, they express frustration with Joe for wanting to “quit.” “That’s not Joe. He’s stubborn. Never quits. He’s been through worse than this, and then went back to work. He must be depressed or not thinking clearly now.”

Is he depressed and not thinking clearly? Psychiatry is consulted to assess Joe’s decisional capacity. He has been informed already that, “We can’t give you something to die. That’s not legal, not in this state.” Although that answer seems to frustrate Joe, he continues to ask that “everything stop.”

No more aggressive treatment. Stop the antibiotics. No more vent. “I want to die.” Joe is deemed to have decisional capacity, per Psych. Ethics thinks so too. The wife, a sister, and two adult children–one of them a nurse in our facility–claim otherwise. “You don’t know Joe. This isn’t him. He isn’t thinking clearly. He’s actually getting better. He can breathe off the vent. His color is much better compared to a week ago. Can you at least not pull the plug for a few days, maybe a week, to give this a chance?” What now should be done for Joe – and his family?

Written by: Tarris Rosell, PhD, DMin

• SOCIETY OF PROFESSIONAL JOURNALISTS

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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 –  Region 6 Mark of Excellence Awards 2023 winners announced –  SPJ condemns The Colorado Republican Party for expelling journalist Sandra Fish from state assembly –  North Carolina General Assembly recipient of Black Hole Award

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

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

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

Dónal O’Mathúna and Ron Iphofen .

Affiliations

Published online: November 3, 2022.

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

1.1. Judging the Ethics of Research

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

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

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

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

1.2. The Case for Cases

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

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

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

1.3. Research Design and Causal Inference

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

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

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

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

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

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

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

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

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

1.4. Devil’s in the Detail

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

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

1.5. Cases and Policymaking

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

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

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

1.6. The Moral Gain

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

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

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

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

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

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

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

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

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

1.7. Into the Future

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

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

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

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

• Cite this Page O’Mathúna D, Iphofen R. Making a Case for the Case: An Introduction. 2022 Nov 3. In: O'Mathúna D, Iphofen R, editors. Ethics, Integrity and Policymaking: The Value of the Case Study [Internet]. Cham (CH): Springer; 2022. Chapter 1. doi: 10.1007/978-3-031-15746-2_1
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• Judging the Ethics of Research
• The Case for Cases
• Research Design and Causal Inference
• Devil’s in the Detail
• Cases and Policymaking
• The Moral Gain
• Into the Future

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Ethics in Finance

Case Studies from a Woman’s Life on Wall Street

• Kara Tan Bhala 0

Seven Pillars Institute for Global Finance and Ethics, Kansas City, USA

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• Winner, International Business Book, UK Business Book Awards 2022
• Bronze medal winner, Business Ethics category, US Axiom Business Book Awards 2022
• Finalist, Nonfiction: Narrative category, International Book Awards 2022

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Table of contents (10 chapters)

Front matter, plantation adventure case study.

Kara Tan Bhala

Bangkok Misadventure Case Study

Hong kong hike case study, mutual fund fun case study, high finance gender inequity case study, hedge fund edge case study, hedge fund harassment case study, whistleblowing consultant case study, finance academy gender inequity case study, finance academy ideological bias case study, back matter.

This award-winning book comprises multiple finance and ethics case studies. The purpose of the book is twofold. First, the case studies teach readers how to evaluate and determine resolutions to ethical issues in finance. Second, the reader will enjoy a journey with the author, a woman, over her years working in finance, through the use of case studies.

Prefaced by the additional of video introductions, these studies focus on ethical issues in finance which the author encountered over nearly a 30-year career in the industry. There are 10 case studies extracted from different sectors of finance. This broad range is a consequence of the author’s experience from almost all sides of the business: the buy side, the sell side, equity research in Asia, equity sales, mutual funds, hedge funds, the finance academy, and consulting.

Apart from ethics determinations, the material in the book covers and explains a variety of specific, and even complex, financial transactions. In every transaction there is an explanation of the roles of various players involved. In this way, readers will learn about the work of people in different positions in finance from investment bankers and equity traders to portfolio managers and equity analysts. Through these case studies, readers also will get an understanding of major financial transactions and activities such as IPOs, secondary offerings, equity trading, and equity valuations.

The book will appeal to practitioners, college and high school students, and lecturers who can use it to supplement courses in finance or business ethics. 

• Women in Finance
• Investment Banking Ethics
• Financial Ethics Case Studies
• Asset Management Ethics
• Equity Sales Ethics
• Asian Markets Financial Ethics
• Hedge Fund Ethics
• Financial Whistleblowers
• investments and securities

Kara Tan Bhala  is the President and Founder of Seven Pillars Institute for Global Finance and Ethics, USA, the world’s only independent think tank for research, education, and promotion of financial ethics. She was an Honorary Research Fellow at Queen Mary University of London, UK and currently sits as a Jury Member for the Ethics and Trust in Finance Global Prize (Switzerland) and is the U.S. Ambassador for the Transparency Task Force (UK). Dr. Tan Bhala has a rare combination of professional training and extensive experience in both global finance and moral philosophy. She has nearly 30 years of experience in global finance, much of which was gained through working on Wall Street. She has been a sell-side equity analyst, a sell-side equity sales person, a buy-side equity analyst, a portfolio manager, and a lecturer in finance. For 18 years she ran her own international financial markets consulting firm. Dr. Tan Bhala has five degrees across three disciplines: a Bachelors (City, University of London, UK) and Masters in Business (Oxford University, UK), a Masters in Liberal Studies (New York University, USA), and a Masters and PhD in Philosophy (University of Kansas, USA). She has lived and worked in London, Oxford, Singapore, Hong Kong, New York, Washington DC., and currently resides in Kansas City. She is a member of the Council on Foreign Relations, USA, and the Royal Society for Asian Affairs, UK.

Book Title : Ethics in Finance

Book Subtitle : Case Studies from a Woman’s Life on Wall Street

Authors : Kara Tan Bhala

DOI : https://doi.org/10.1007/978-3-031-34401-5

Publisher : Palgrave Macmillan Cham

eBook Packages : Economics and Finance , Economics and Finance (R0)

Copyright Information : The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023

Softcover ISBN : 978-3-031-34400-8 Published: 29 June 2023

eBook ISBN : 978-3-031-34401-5 Published: 28 June 2023

Edition Number : 2

Number of Pages : XXIII, 122

Number of Illustrations : 1 b/w illustrations, 1 illustrations in colour

Topics : Investments and Securities , Business Ethics , Behavioral Finance

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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.

Applying Virtue Ethics: The Rajat Gupta Case

A short introduction to virtue ethics                                   .

Virtue ethics is an agent-based approach to ethics. This approach focuses on the fundamental character and motivations of the individual moral agent. Moral behavior is not limited or attached to a rule or any guidelines, but rather involves the individual rationally pursuing moral excellence as a goal in and of itself. According to Aristotelian virtue ethics, virtue is defined as a desirable character trait, such as courage, that lies between two extremes, rashness and cowardice. The virtuous agent is involved in a continual quest to find balance in ethical decision-making. Such an agent does not apply any specific ‘rules’ in making ethical decisions, but rather attempts to make decisions that are consistent with the pursuit of a particular kind of excellence that entails exercising sound moral judgment guided by virtues like courage, wisdom, temperance, fairness, integrity and consistency.

Virtue ethics is currently one of three major approaches in normative ethics . It may, initially, be identified as the one that emphasizes the virtues, or moral character , in contrast to the approach that emphasizes duties or rules ( deontology ) or that which emphasizes the consequences of actions ( consequentialism ).

Suppose it is obvious that someone in need should be helped. A utilitarian will point to the fact that the consequences of doing so maximizes happiness of those affected by the act of helping. A deontologist points to the fact that, in helping the one in need, the agent is acting in accordance with a moral rule such as “Do unto others as you would be done by”. A virtue ethicist points to the fact that helping the person is exercising the character trait of benevolence. All the three moral theories will agree that helping the person in need is ethically correct.

Aristotle is an early developer of virtue ethics. Aristotle writes, “ The virtue of man also will be the state of character which makes a man good and which makes him do his own work well “. The aim is to perform the right action, with the right person, to the right extent, at the right time, and in the right way. Although this is the objective, Aristotle considers achieving this goodness as rare, laudable, and noble

Aristotle believes people are naturally suited to do the right thing, but do not automatically develop such inclinations to do “ good ”. He strongly believes you are what you do, so in that respect the ideal virtuous person does the right thing because she desires to be virtuous. One cannot be accidentally or coincidentally virtuous.

The virtue ethics approach focuses on the “ integrity” of the moral actor. The goal with this approach is to be a good person. In virtue ethics, one’s character emerges from a “ relevant moral community ”.   Therefore, it is important to account for the moral agent’s community or communities within which she operates. This approach is particularly useful for individuals who work within a professional community that has developed high standards of ethical conduct for community members

Moral Virtue is a Habit

Aristotle’s criteria for the virtuous person is as follows: You must have knowledge, consciously choose the acts and choose them for their own sake, and the choice must come from a firm character, in accordance to who you are. You must consistently choose to do good acts deliberately for the right reasons. You cannot be considered virtuous for catching a ball before it hits a child in a baseball game thus saving that child, if you simply wanted to catch the ball and take it home with you as a trophy to show to your friends. You should have saved the child from the incoming ball out of genuine virtue and care towards the child.

To achieve the ability to be moral requires developing the proper character. To develop the proper character requires developing virtues. To develop virtues requires developing moral habits. Aristotle said, “B y abstaining from pleasures we become temperate, and it is when we have become so that we are most able to abstain from them “. What begins as a great effort to give up, in time and with effort and practice becomes quite normal and is no effort at all. Aristotle also believes we learn virtue by doing the right things constantly until we are habituated. We learn by doing as children and character is the result of habits, which in turn, are developed from repeated actions.

There are 2 types of virtues. Intellectual Virtues are excellences of the mind, for example, the ability to understand, reason, & judge well. Intellectual virtue comes from being taught. Moral Virtues are learned by repetition. For example, by practicing honesty we become honest. To be virtuous requires knowledge, practice & consistent effort for character building. Moral virtue results from developing proper habits. Neither intellectual nor moral virtue arise without active intervention and participation. According to Aristotle, “ We first acquire the potentiality and later exhibit the activity “. We develop virtues by practicing them. In a similar vein, we learn the arts and music. We learn virtues by doing them repeatedly and forming the correct habits as a young basketball player learning to shoot the ball.

In personal/life development, virtue ethics transforms the meaning of doing “ What is right and wrong? ” to “ What kind of person you are and does this action fit into what you are? ” Virtue ethics in personal development allows a dynamic way of thinking that allows a person to grow and to learn that everything is not black and white.

A virtuous person is not simply one who just does a good or right act once in a while, rather a virtuous person is someone who “ consistently” chooses the right acts for the right motives. Being virtuous is a habitual act and you are what you do. If you lie constantly, you are a liar and the act of lying establishes that character trait in you. In business, if you cut corners and practice unethical business tactics you are an unethical businessman.

Virtue Ethics Theory Applied:             

Rajat gupta and insider trading, the players.

Rajat Gupta is an Indian American businessman who was the managing director of management consultancy McKinsey & Company and a business leader in India and the United States. Rajat Gupta also served as corporate chairman, board director or strategic advisor to Goldman Sachs , Procter and Gamble and American Airlines , and non-profits organizations, The Gates Foundation , The Global Fund and the International Chamber of Commerce .

Rajat Gupta was convicted in June 2012 on insider trading charges. He was sentenced in October 2012 to two years in prison, an additional year on supervised release and ordered to pay $5 million in fines. His trial began on May 22, 2012. On June 15, 2012, Gupta was found guilty on three counts of securities fraud and one count of conspiracy.

The primary parties are affected are Rajat Gupta, McKinsley & Company, Goldman Sachs, Raj Rajaratnam, Galleon Group, Warren Buffet, and the U.S. equity markets. Other parties indirectly affected are family and friends of Rajat Gupta, employees at McKinsley & Company and Galleon Group, investors in Goldman Sachs and its creditors, and government and officials involved with the case.

The Transactions

In September 2008 Warren Buffet agrees to pay $5 billion to Goldman Sachs in exchange for preferred shares in the company. This news is likely to raise the share price of Goldman Sachs. The news is not supposed to be announced and made public until the end of day. Less than a minute after the board approved the Buffet purchase, Rajat Gupta calls his longtime friend Raj Rajaratnam, a hedge fund manager and billionaire founder of Galleon Group. Once Rajaratnam gets this information, he immediately buys shares of Goldman Sachs. Next day when the stock market opens, Raj Rajaratnam makes nearly $1.2 million in profits as Goldman Sachs shares rose. The SEC estimates the tip leaked by Rajat Gupta generates profits and avoids losses of more than $23 million.

Ethical Analysis

Would a virtuous person have leaked the information to Raj Rajaratnam? Rajat Gupta showed a failure of character:

Integrity : Integrity is honesty and truthfulness or accuracy of a person’s action. Rajat Gupta does not show integrity to his company Goldman Sachs, where he was a Board of Director. Instead gives away insider information for personal benefits.

Trust : Rajat Gupta broke the trust to other Directors on Goldman’s board and to of other people with whom he has done business. His actions affect the relationship with McKinsley & Company.

Fairness: Rajat Gupta’s actions are not fair for two reasons. First, other investors who do not have the information on Buffett’s deal are at a disadvantage. Second, he uses the information entrusted to him to benefit himself and Rajaratnam.

Honesty: He was not honest with Goldman Sachs and his fellow board members to whom he implicitly promised not to share inside information.

Self-Control: If Rajat Gupta had self-control he would not have leaked inside information to Rajaratnam for personal gain.

Gupta was commended by people who knew him as a person who helped others. He was very active in providing medical and humanitarian relief to the developing countries. Born to humble circumstances, he became a pillar of the consulting community and a trusted advisor to the world’s leading companies and organizations. A word that was used repeatedly in media coverage for Rajat Gupta during his trial was “ respected .” In the past, much less so now, we assume people in leadership positions are virtuous. However, instances like the Rajat Gupta insider trading case and other financial scandals remind us that the assumption is not well-founded

As a true professional, the good manager strives to achieve a moral excellence that includes honesty, fairness, prudence , and courage. Various mechanisms are suggested to develop moral character amongst practitioners and avoid ethical lapses as in the Rajat Gupta case. Suggestions include tighter government regulations, better systems and processes in financial institutions, enhanced corporate governance, and increasing the awareness of customers. Yet, a root of the problem is not addressed: not teaching financial ethics in business schools, where moral decision making should be the core lesson. If business schools provide future financial managers with a proper ethical education, there is a chance that situations like “Rajat Gupta and Insider Trading” may occur less frequently.

By: Pratik Patel

Works Cited

• http://www.innovation.cc/scholarly-style/virtue-ethics-corruption.htm
• Linda K. Trevino, Katherine A Nelson, “Managing Business Ethics”, (2010) Fifth Edition
• James Rachel, “The Elements of Moral Philosophy”, (2009) Sixth Edition
• Raj Gupta: Virtue is never a Given, Retrieved from
• http://www.forbes.com/sites/johnbaldoni/2012/10/25/raj-gupta-virtue-is-never-a-given/
• Blame Business Schools, Electronics Resource, Retrieved from http://www.businessweek.com/debateroom/archives/2008/11/us_financial_cr.html
• http://ejbo.jyu.fi/articles/0901_3.html
• http://edoc.ub.uni-muenchen.de/12156/1/Villa_Jesus_Simeon.pdf
• John Graafland & Bret Van de Ven, “The Credit Crisis & the Moral Responsibility of Professional in Finance”
• Normative Ethics
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• Consequentialism
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• Insider Trading
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US-Russian Contention in Cyberspace

The overarching question imparting urgency to this exploration is: Can U.S.-Russian contention in cyberspace cause the two nuclear superpowers to stumble into war? In considering this question we were constantly reminded of recent comments by a prominent U.S. arms control expert: At least as dangerous as the risk of an actual cyberattack, he observed, is cyber operations’ “blurring of the line between peace and war.” Or, as Nye wrote, “in the cyber realm, the difference between a weapon and a non-weapon may come down to a single line of code, or simply the intent of a computer program’s user.”

The Geopolitics of Renewable Hydrogen

Renewables are widely perceived as an opportunity to shatter the hegemony of fossil fuel-rich states and democratize the energy landscape. Virtually all countries have access to some renewable energy resources (especially solar and wind power) and could thus substitute foreign supply with local resources. Our research shows, however, that the role countries are likely to assume in decarbonized energy systems will be based not only on their resource endowment but also on their policy choices.

What Comes After the Forever Wars

As the United States emerges from the era of so-called forever wars, it should abandon the regime change business for good. Then, Washington must understand why it failed, writes Stephen Walt.

Telling Black Stories: What We All Can Do

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These studies provide a foundation for discussing ethical issues so we can better integrate data ethics in real life.

To help us think seriously about data ethics, we need case studies that we can discuss, argue about, and come to terms with as we engage with the real world. Good case studies give us the opportunity to think through problems before facing them in real life. And case studies show us that ethical problems aren't simple. They are multi-faceted, and frequently there's no single right answer. And they help us to recognize there are few situations that don't raise ethical questions.

Princeton's  Center for Information Technology Policy  and  Center for Human Values  have created four anonymized  case studies  to promote the discussion of ethics. The first of these studies,  Automated Healthcare App , discusses a smartphone app designed to help adult onset diabetes patients. It raises issues like paternalism, consent, and even language choices. Is it OK to “nudge” patients toward more healthy behaviors? What about automatically moderating the users’ discussion groups to emphasize scientifically accurate information? And how do you deal with minorities who don’t respond to treatment as well? Could the problem be the language itself that is used to discuss treatment?

The next case study,  Dynamic Sound Identification , covers an application that can identify voices, raising issues about privacy, language, and even gender. How far should developers go in identifying potential harm that can be caused by an application? What are acceptable error rates for an application that can potentially do harm? How can a voice application handle people with different accents or dialects? And what responsibility do developers have when a small experimental tool is bought by a large corporation that wants to commercialize it?

The  Optimizing Schools  case study deals with the problem of finding at-risk children in school systems. Privacy and language are again an issue; it also raises the issue of how decisions to use data are made. Who makes those decisions, and who needs to be informed about them? What are the consequences when people find out how their data has been used? And how do you interpret the results of an experiment? Under what conditions can you say that a data experiment has really yielded improved educational results?

The final case study,  Law Enforcement Chatbots , raises issues about the tradeoff between liberty and security, entrapment, openness and accountability, and compliance with international law.

None of these issues are simple, and there are few (if any) "right answers." For example, it’s easy to react against perceived paternalism in a medical application, but the purpose of such an application is to encourage patients to comply with their treatment program. It’s easy to object to monitoring students in a public school, but students are minors, and schools by nature handle a lot of private personal data. Where is the boundary between what is, and isn’t, acceptable? What's important isn’t getting to the correct answer on any issue, but to make sure the issue is discussed and understood, and that we know what tradeoffs we are making. What is important is that we get practice in discussing ethical issues and put that practice to work in our jobs. That’s what these case studies give us.

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The authors.

• Senior Fellow, Technology and Public Purpose Project
• Former Senior Fellow, Cyber Project
• Former U.S Chief Data Scientist
• Former CTO, Devoted Health
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Find ethical case studies on leadership ethics, including scenarios for top management on issues such as downsizing and management responsibilities. (For permission to reprint articles, submit requests to  [email protected] .)

Extensive teaching note based on interviews with Theranos whistleblower Tyler Shultz. The teaching note can be used to explore issues around whistleblowing, leadership, the blocks to ethical behavior inside organizations, and board governance.

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Exploring the ethical dilemmas of emergency care on the front lines

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Rachel Whitmoyer brings her work as an emergency medical technician to bear on her philosophy studies at Rochester.

As an emergency medical technician (EMT) since 2020, Rachel Whitmoyer ’24 has helped countless patients facing dire situations. But she also has dealt with less-extreme scenarios, including one man who demanded transport to the hospital via ambulance because of . . . hiccups.

That incident proved annoying and enlightening for Whitmoyer, a double major in physics and philosophy at the University of Rochester who hails from Lebanon, Pennsylvania.

“It’s easy to become frustrated when the area you service is short on first responders and policy requires you to transport non-emergent patients to the hospital,” she says. “But even if a patient isn’t in need of immediate medical care, they may not have the background necessary to recognize that. They can be scared, confused, and stressed.”

Situations like this prompted Whitmoyer to dedicate her senior thesis to exploring the biomedical ethical issues faced by EMTs. “So much of health care emphasizes curing patients as a solitary goal,” she says. “But high-quality patient care cannot exist without realizing that a patient is a person, and not a problem to be solved.”

Ambulances and academia

Whitmoyer’s thesis focuses on a few points: justice considerations in triage and resource allocation in prehospital and hospital settings, the benefits that Emergency Medical Services–initiated refusal of transport protocols have on individuals and communities, and why Do Not Resuscitate (DNR) orders outside of hospitals often don’t honor patients’ autonomy in end-of-life health care decisions.

“My goal is to address how unyielding legal requirements have taken precedence over patient-specific care over the past few decades, and the potential solutions that would allow providers to maintain a balance of both,” Whitmoyer says.

Her research involves synthesizing the results from previous studies and analyzing them from an ethical perspective. “For instance, I’ve been utilizing studies quantifying unnecessary ambulance use and studies discussing unwanted resuscitation attempts in patients with DNR orders,” she says. “Being able to connect with subject-specific University librarians was extremely helpful in beginning the research process, as well as what I learned in my introductory writing and philosophy courses.”

Cases lacking genuine medical need can stretch limited resources and compromise the ability of EMTs to attend to genuine emergencies.

Pennsylvania is one of 13 states that deem EMS an essential service eligible for state funding. No one can be denied a ride to the hospital in an ambulance—although not everyone needs it, hiccups or otherwise.

“People assume that they will get to the front of the line in the emergency department if they arrive in an ambulance,” Whitmoyer says. “That’s not true, unless they’re in a cardiac or high-acuity situation. Anyone not facing a life-threatening situation usually has to wait.”

From EMT to physics and philosophy—by way of the Rochester curriculum

William FitzPatrick , the Gideon Webster Burbank Professor of Intellectual and Moral Philosophy at Rochester and Whitmoyer’s thesis adviser, says she’s “a particularly impressive and ambitious student” with an exceptional work ethic.

“Combining hard science, philosophy, and medicine is extraordinary, especially with the addition of a senior thesis project,” he adds.

FitzPatrick says Whitmoyer’s thesis explores interesting and timely questions about how to balance deference to patient demands for emergency hospital transportation with professional judgment concerning genuine medical need.

“Current policy is weighted in favor of deferring to patient demands,” he says. “But in cases lacking genuine medical need this can stretch resources and compromise the ability of EMTs to attend to genuine emergencies; on the other hand, refusal of transport in such cases raises its own problems unless the underlying social challenges and vulnerabilities are also addressed.”

Whitmoyer took classes with FitzPatrick in her sophomore and junior years and wrote a paper about the limitations of obtaining informed consent in medical emergencies. She so enjoyed doing the research and connecting it to her experiences as an EMT that she decided to take on an additional project this year to explore more of the ethical issues in pre-hospital emergency medicine.

Whitmoyer entered the University as a physics major in 2020 but added philosophy as a second major her sophomore year. She says Rochester’s flexible undergraduate curriculum made it possible to major in two non-related fields. “Going into my first semester and being able to choose classes and explore my interests gave me lots of flexibility,” she says. “I took some philosophy courses and just fell in love with it.”

One of the early impactful classes was Philosophy 105: Reason and Argument, with associate professor Zeynep Soysal.

“That class taught me that learning how to construct a good argument makes it much easier not only to effectively communicate your ideas but also to analyze information coming from other sources,” Whitmoyer says.

Answering the call

Whitmoyer took an EMT class in high school and became certified in June 2020, when the COVID-19 pandemic was surging. She’s affiliated with two companies back in Pennsylvania—one paid and one volunteer—and during summers she can work up to 60 hours per week. She usually works 12-hour shifts and always has at least one partner.

The first step when responding to a call is determining the patient’s level of consciousness and the reason EMTs were summoned. Whitmoyer may have to administer oxygen or medication or perform life-saving interventions to control high-acuity issues relating to airway, breathing, or circulation. The EMTs contact the hospital’s emergency department via radio to alert them of their impending arrival and provide a patient care report that details pertinent findings or interventions performed.

“My favorite part is getting to advocate for my patients and help mitigate stress in some of the most emotional moments of their lives,” she says. “I am often a stranger to many of the people I meet on scene and view it as an immense honor and privilege to be given their trust. Driving with lights and sirens on is pretty cool, too.”

Whitmoyer plans to pursue a career as an emergency medicine physician, which she will train for as she completes a military medical residency under the US Army’s Health Professions Scholarship Program after graduating medical school.

“My grandfather is an Army veteran, and many other family members have served,” she says.

Whitmoyer doesn’t rule out continuing as an EMT long term, either.

“I’d love to be able to pick up shifts if time allows,” she says. “The work is so rewarding.”

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My sister Falana became a case study in health inequities (Viewpoint)

• Updated: Apr. 09, 2024, 4:24 p.m. |
• Published: Apr. 09, 2024, 4:13 p.m.
• Tania Barber

We often think about health inequities in Massachusetts in terms of numbers. One example: the Center for Health Information and Analysis found that Black and Hispanic Massachusetts residents are significantly less likely to secure an appointment with a doctor’s office or clinic as soon as needed.

Compounding these difficulties, one third of Hispanic residents and over one quarter of Black residents reported unmet health care needs due to cost.

Figures like these paint a disturbing picture of systemic racism, but health inequities take on a different level of urgency when we look at real people and stories behind the data. People of color across the Commonwealth experience care delayed, care denied, and avoidable complications, all adding up to an uncountable number of personal tragedies in a system that leaves so many behind.

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Business negotiation tactics to use in everyday life

Marielle Segarra

Negotiation skills aren't just for high-stakes situations like job offers and pay raises. They can be used in daily life, like figuring out where you and your friends should go on vacation or what you and your partner should cook for dinner tonight.

They can also help you get what you want and make decisions with more confidence, says Joan Moon , a career coach and the head of negotiation coaching at the Negotiation and Conflict Resolution Collaboratory at the Harvard Kennedy School. "They can improve your satisfaction with your situation and give you a sense that you are making intentional choices."

Moon explains four classic negotiation tactics often used in business environments — and how they can be applied in everyday circumstances.

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The tactic: benchmarking.

This strategy allows you to gather the information you need to make a fair decision. It's when you compare an offer to market standards and best practices, "then figure out where you lie within that range" to get an optimal deal. People often use benchmarking in salary negotiations to ensure they're being paid equitably, says Moon.

How to use it in everyday life: Use this tactic when making big consumer choices, says Moon — like hiring a contractor to renovate your kitchen or buying a car. "What you're doing is researching good information and an appropriate price point for this purchase" to align your budget and the industry standards.

The tactic: Win-win strategy

This helps different parties find one solution that's in everyone's interest. You might see this in business contracts or labor agreements, for example. Parties won't sign until the terms are mutually beneficial.

How to use it in everyday life: Try this when you want the other party to not just agree with your decision, but feel good about it. Moon shares a recent personal experience. Her phone line was down so she called her phone company to get reconnected — but the customer service agents were unhelpful. She could feel herself getting upset, so she decided to reframe her request using a win-win strategy. She said: "Listen, I've been with this company for ten years and I would like to keep doing so for another ten years. Can we focus on a solution?"

3 common thinking traps and how to avoid them, according to a Yale psychologist

The approach worked, she says. The company didn't want to lose a loyal customer — and Moon wanted her phone fixed.

The tactic: A menu of options

This approach avoids requests that result in a simple yes or no answer. People often use this tactic when negotiating the benefits of a job offer, says Moon. For example, instead of asking for more flexibility at a new job and getting a flat-out no, you might propose a couple of options: working three days remote or a four-day workweek, expanding the possibility of a favorable outcome.

How to use it in everyday life: Offer "a menu of options" to someone if they think only one solution is possible. Let's say you're upset with your roommate for being messy, says Moon. Instead of asking them to clean up (which they haven't been doing), give them choices: hire a housekeeper, change the breakdown of responsibilities at home or adjust the cleaning schedule. "When you present options, it signals to the other person: let's solve this problem together," says Moon.

The rules of improv can make you funnier. They can also make you more confident.

The tactic: best alternative to negotiated agreement.

Negotiators use BATNA to come up with a backup plan when their desired outcome isn't possible. It helps avoid a total win-lose situation. You might use BATNA when comparing job offers with unfavorable conditions. For example, one job requires you to relocate your family to another state, while the other job pays less but is local. Your BATNA might be to stay at your current gig and keep job-hunting until you find something better.

How to use it in everyday life: You can use BATNA for the smallest decisions, like figuring out what to eat for dinner. Let's say your partner wants to stay in and cook tacos but you're not craving it. So you propose your BATNA — you'll go out for a burger instead. Yes, you'll have to leave the house, but you won't need to cook or clean up the kitchen.

The digital story was written by Malaka Gharib and edited by Margaret Cirino and Meghan Keane. The visual editor is Beck Harlan. We'd love to hear from you. Leave us a voicemail at 202-216-9823, or email us at [email protected].

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O.J. Simpson, Football Star Whose Trial Riveted the Nation, Dies at 76

He ran to football fame and made fortunes in movies. His trial for the murder of his former wife and her friend became an inflection point on race in America.

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By Robert D. McFadden

O.J. Simpson, who ran to fame on the football field, made fortunes as an all-American in movies, television and advertising, and was acquitted of killing his former wife and her friend in a 1995 trial in Los Angeles that mesmerized the nation, died on Wednesday at his home in Las Vegas. He was 76.

The cause was cancer, his family announced on social media.

The jury in the murder trial cleared him, but the case, which had held up a cracked mirror to Black and white America, changed the trajectory of his life. In 1997, a civil suit by the victims’ families found him liable for the deaths of Nicole Brown Simpson and Ronald L. Goldman, and ordered him to pay $33.5 million in damages. He paid little of the debt, moved to Florida and struggled to remake his life, raise his children and stay out of trouble.

In 2006, he sold a book manuscript, titled “If I Did It,” and a prospective TV interview, giving a “hypothetical” account of murders he had always denied committing. A public outcry ended both projects, but Mr. Goldman’s family secured the book rights, added material imputing guilt to Mr. Simpson and had it published.

In 2007, he was arrested after he and other men invaded a Las Vegas hotel room of some sports memorabilia dealers and took a trove of collectibles. He claimed that the items had been stolen from him, but a jury in 2008 found him guilty of 12 charges, including armed robbery and kidnapping, after a trial that drew only a smattering of reporters and spectators. He was sentenced to nine to 33 years in a Nevada state prison. He served the minimum term and was released in 2017.

Over the years, the story of O.J. Simpson generated a tide of tell-all books, movies, studies and debate over questions of justice, race relations and celebrity in a nation that adores its heroes, especially those cast in rags-to-riches stereotypes, but that has never been comfortable with its deeper contradictions.

There were many in the Simpson saga. Yellowing old newspaper clippings yield the earliest portraits of a postwar child of poverty afflicted with rickets and forced to wear steel braces on his spindly legs, of a hardscrabble life in a bleak housing project and of hanging with teenage gangs in the tough back streets of San Francisco, where he learned to run.

“Running, man, that’s what I do,” he said in 1975, when he was one of America’s best-known and highest-paid football players, the Buffalo Bills’ electrifying, swivel-hipped ball carrier, known universally as the Juice. “All my life I’ve been a runner.”

And so he had — running to daylight on the gridiron of the University of Southern California and in the roaring stadiums of the National Football League for 11 years; running for Hollywood movie moguls, for Madison Avenue image-makers and for television networks; running to pinnacles of success in sports and entertainment.

Along the way, he broke college and professional records, won the Heisman Trophy and was enshrined in pro football’s Hall of Fame. He appeared in dozens of movies and memorable commercials for Hertz and other clients; was a sports analyst for ABC and NBC; acquired homes, cars and a radiant family; and became an American idol — a handsome warrior with the gentle eyes and soft voice of a nice guy. And he played golf.

It was the good life, on the surface. But there was a deeper, more troubled reality — about an infant daughter drowning in the family pool and a divorce from his high school sweetheart; about his stormy marriage to a stunning young waitress and her frequent calls to the police when he beat her; about the jealous rages of a frustrated man.

Calls to the Police

The abuse left Nicole Simpson bruised and terrified on scores of occasions, but the police rarely took substantive action. After one call to the police on New Year’s Day, 1989, officers found her badly beaten and half-naked, hiding in the bushes outside their home. “He’s going to kill me!” she sobbed. Mr. Simpson was arrested and convicted of spousal abuse, but was let off with a fine and probation.

The couple divorced in 1992, but confrontations continued. On Oct. 25, 1993, Ms. Simpson called the police again. “He’s back,” she told a 911 operator, and officers once more intervened.

Then it happened. On June 12, 1994, Ms. Simpson, 35, and Mr. Goldman, 25, were attacked outside her condominium in the Brentwood section of Los Angeles, not far from Mr. Simpson’s estate. She was nearly decapitated, and Mr. Goldman was slashed to death.

The knife was never found, but the police discovered a bloody glove at the scene and abundant hair, blood and fiber clues. Aware of Mr. Simpson’s earlier abuse and her calls for help, investigators believed from the start that Mr. Simpson, 46, was the killer. They found blood on his car and, in his home, a bloody glove that matched the one picked up near the bodies. There was never any other suspect.

Five days later, after Mr. Simpson had attended Nicole’s funeral with their two children, he was charged with the murders, but fled in his white Ford Bronco. With his old friend and teammate Al Cowlings at the wheel and the fugitive in the back holding a gun to his head and threatening suicide, the Bronco led a fleet of patrol cars and news helicopters on a slow 60-mile televised chase over the Southern California freeways.

Networks pre-empted prime-time programming for the spectacle, some of it captured by news cameras in helicopters, and a nationwide audience of 95 million people watched for hours. Overpasses and roadsides were crowded with spectators. The police closed highways and motorists pulled over to watch, some waving and cheering at the passing Bronco, which was not stopped. Mr. Simpson finally returned home and was taken into custody.

The ensuing trial lasted nine months, from January to early October 1995, and captivated the nation with its lurid accounts of the murders and the tactics and strategy of prosecutors and of a defense that included the “dream team” of Johnnie L. Cochran Jr. , F. Lee Bailey , Alan M. Dershowitz, Barry Scheck and Robert L. Shapiro.

The prosecution, led by Marcia Clark and Christopher A. Darden, had what seemed to be overwhelming evidence: tests showing that blood, shoe prints, hair strands, shirt fibers, carpet threads and other items found at the murder scene had come from Mr. Simpson or his home, and DNA tests showing that the bloody glove found at Mr. Simpson’s home matched the one left at the crime scene. Prosecutors also had a list of 62 incidents of abusive behavior by Mr. Simpson against his wife.

But as the trial unfolded before Judge Lance Ito and a 12-member jury that included 10 Black people, it became apparent that the police inquiry had been flawed. Photo evidence had been lost or mislabeled; DNA had been collected and stored improperly, raising a possibility that it was tainted. And Detective Mark Fuhrman, a key witness, admitted that he had entered the Simpson home and found the matching glove and other crucial evidence — all without a search warrant.

‘If the Glove Don’t Fit’

The defense argued, but never proved, that Mr. Fuhrman planted the second glove. More damaging, however, was its attack on his history of racist remarks. Mr. Fuhrman swore that he had not used racist language for a decade. But four witnesses and a taped radio interview played for the jury contradicted him and undermined his credibility. (After the trial, Mr. Fuhrman pleaded no contest to a perjury charge. He was the only person convicted in the case.)

In what was seen as the crucial blunder of the trial, the prosecution asked Mr. Simpson, who was not called to testify, to try on the gloves. He struggled to do so. They were apparently too small.

“If the glove don’t fit, you must acquit,” Mr. Cochran told the jury later.

In the end, it was the defense that had the overwhelming case, with many grounds for reasonable doubt, the standard for acquittal. But it wanted more. It portrayed the Los Angeles police as racist, charged that a Black man was being railroaded, and urged the jury to think beyond guilt or innocence and send a message to a racist society.

On the day of the verdict, autograph hounds, T-shirt vendors, street preachers and paparazzi engulfed the courthouse steps. After what some news media outlets had called “The Trial of the Century,” producing 126 witnesses, 1,105 items of evidence and 45,000 pages of transcripts, the jury — sequestered for 266 days, longer than any in California history — deliberated for only three hours.

Much of America came to a standstill. In homes, offices, airports and malls, people paused to watch. Even President Bill Clinton left the Oval Office to join his secretaries. In court, cries of “Yes!” and “Oh, no!” were echoed across the nation as the verdict left many Black people jubilant and many white people aghast.

In the aftermath, Mr. Simpson and the case became the grist for television specials, films and more than 30 books, many by participants who made millions. Mr. Simpson, with Lawrence Schiller, produced “I Want to Tell You,” a thin mosaic volume of letters, photographs and self-justifying commentary that sold hundreds of thousands of copies and earned Mr. Simpson more than $1 million.

He was released after 474 days in custody, but his ordeal was hardly over. Much of the case was resurrected for the civil suit by the Goldman and Brown families. A predominantly white jury with a looser standard of proof held Mr. Simpson culpable and awarded the families $33.5 million in damages. The civil case, which excluded racial issues as inflammatory and speculative, was a vindication of sorts for the families and a blow to Mr. Simpson, who insisted that he had no chance of ever paying the damages.

Mr. Simpson had spent large sums for his criminal defense. Records submitted in the murder trial showed his net worth at about $11 million, and people with knowledge of the case said he had only $3.5 million afterward. A 1999 auction of his Heisman Trophy and other memorabilia netted about $500,000, which went to the plaintiffs. But court records show he paid little of the balance that was owed.

He regained custody of the children he had with Ms. Simpson, and in 2000 he moved to Florida, bought a home south of Miami and settled into a quiet life, playing golf and living on pensions from the N.F.L., the Screen Actors Guild and other sources, about $400,000 a year. Florida laws protect a home and pension income from seizure to satisfy court judgments.

The glamour and lucrative contracts were gone, but Mr. Simpson sent his two children to prep school and college. He was seen in restaurants and malls, where he readily obliged requests for autographs. He was fined once for powerboat speeding in a manatee zone, and once for pirating cable television signals.

In 2006, as the debt to the murder victims’ families grew with interest to $38 million, he was sued by Fred Goldman, the father of Ronald Goldman, who contended that his book and television deal for “If I Did It” had advanced him $1 million and that it had been structured to cheat the family of the damages owed.

The projects were scrapped by News Corporation, parent of the publisher HarperCollins and the Fox Television Network, and a corporation spokesman said Mr. Simpson was not expected to repay an $800,000 advance. The Goldman family secured the book rights from a trustee after a bankruptcy court proceeding and had it published in 2007 under the title “If I Did It: Confessions of the Killer.” On the book’s cover, the “If” appeared in tiny type, and the “I Did It” in large red letters.

Another Trial, and Prison

After years in which it seemed he had been convicted in the court of public opinion, Mr. Simpson in 2008 again faced a jury. This time he was accused of raiding a Las Vegas hotel room in 2007 with five other men, most of them convicted criminals and two armed with guns, to steal a trove of sports memorabilia from a pair of collectible dealers.

Mr. Simpson claimed that he was only trying to retrieve items stolen from him, including eight footballs, two plaques and a photo of him with the F.B.I. director J. Edgar Hoover, and that he had not known about any guns. But four men, who had been arrested with him and pleaded guilty, testified against him, two saying they had carried guns at his request. Prosecutors also played hours of tapes secretly recorded by a co-conspirator detailing the planning and execution of the crime.

On Oct. 3 — 13 years to the day after his acquittal in Los Angeles — a jury of nine women and three men found him guilty of armed robbery, kidnapping, assault, conspiracy, coercion and other charges. After Mr. Simpson was sentenced to a minimum of nine years in prison, his lawyer vowed to appeal, noting that none of the jurors were Black and questioning whether they could be fair to Mr. Simpson after what had happened years earlier. But jurors said the double-murder case was never mentioned in deliberations.

In 2013, the Nevada Parole Board, citing his positive conduct in prison and participation in inmate programs, granted Mr. Simpson parole on several charges related to his robbery conviction. But the board left other verdicts in place. His bid for a new trial was rejected by a Nevada judge, and legal experts said that appeals were unlikely to succeed. He remained in custody until Oct. 1, 2017, when the parole board unanimously granted him parole when he became eligible.

Certain conditions of Mr. Simpson’s parole — travel restrictions, no contacts with co-defendants in the robbery case and no drinking to excess — remained until 2021, when they were lifted, making him a completely free man.

Questions about his guilt or innocence in the murders of his former wife and Mr. Goldman never went away. In May 2008, Mike Gilbert, a memorabilia dealer and former crony, said in a book that Mr. Simpson, high on marijuana, had admitted the killings to him after the trial. Mr. Gilbert quoted Mr. Simpson as saying that he had carried no knife but that he had used one that Ms. Simpson had in her hand when she opened the door. He also said that Mr. Simpson had stopped taking arthritis medicine to let his hands swell so that they would not fit the gloves in court. Mr. Simpson’s lawyer Yale L. Galanter denied Mr. Gilbert’s claims, calling him delusional.

In 2016, more than 20 years after his murder trial, the story of O.J. Simpson was told twice more for endlessly fascinated mass audiences on television. “The People v. O.J. Simpson,” Ryan Murphy’s installment in the “American Crime Story” anthology on FX, focused on the trial itself and on the constellation of characters brought together by the defendant (played by Cuba Gooding Jr.). “O.J.: Made in America,” a five-part, nearly eight-hour installment in ESPN’s “30 for 30” documentary series (it was also released in theaters), detailed the trial but extended the narrative to include a biography of Mr. Simpson and an examination of race, fame, sports and Los Angeles over the previous half-century.

A.O. Scott, in a commentary in The New York Times, called “The People v. O.J. Simpson” a “tightly packed, almost indecently entertaining piece of pop realism, a Dreiser novel infused with the spirit of Tom Wolfe” and said “O.J.: Made in America” had “the grandeur and authority of the best long-form fiction.”

In Leg Braces as a Child

Orenthal James Simpson was born in San Francisco on July 9, 1947, one of four children of James and Eunice (Durden) Simpson. As an infant afflicted with the calcium deficiency rickets, he wore leg braces for several years but outgrew his disability. His father, a janitor and cook, left the family when the child was 4, and his mother, a hospital nurse’s aide, raised the children in a housing project in the tough Potrero Hill district.

As a teenager, Mr. Simpson, who hated the name Orenthal and called himself O.J., ran with street gangs. But at 15 he was introduced by a friend to Willie Mays, the renowned San Francisco Giants outfielder. The encounter was inspirational and turned his life around, Mr. Simpson recalled. He joined the Galileo High School football team and won All-City honors in his senior year.

In 1967, Mr. Simpson married his high school sweetheart, Marguerite Whitley. The couple had three children, Arnelle, Jason and Aaren. Shortly after their divorce in 1979, Aaren, 23 months old, fell into a swimming pool at home and died a week later.

Mr. Simpson married Nicole Brown in 1985; the couple had a daughter, Sydney, and a son, Justin. He is survived by Arnelle, Jason, Sydney and Justin Simpson and three grandchildren, his lawyer Malcolm P. LaVergne said.

After being released from prison in Nevada in 2017, Mr. Simpson moved into the Las Vegas country club home of a wealthy friend, James Barnett, for what he assumed would be a temporary stay. But he found himself enjoying the local golf scene and making friends, sometimes with people who introduced themselves to him at restaurants, Mr. LaVergne said. Mr. Simpson decided to remain in Las Vegas full time. At his death, he lived right on the course of the Rhodes Ranch Golf Club.

From his youth, Mr. Simpson was a natural on the gridiron. He had dazzling speed, power and finesse in a broken field that made him hard to catch, let alone tackle. He began his collegiate career at San Francisco City College, scoring 54 touchdowns in two years. In his third year he transferred to Southern Cal, where he shattered records — rushing for 3,423 yards and 36 touchdowns in 22 games — and led the Trojans into the Rose Bowl in successive years. He won the Heisman Trophy as the nation’s best college football player of 1968. Some magazines called him the greatest running back in the history of the college game.

His professional career was even more illustrious, though it took time to get going. The No. 1 draft pick in 1969, Mr. Simpson went to the Buffalo Bills — the league’s worst team had the first pick — and was used sparingly in his rookie season; in his second, he was sidelined with a knee injury. But by 1971, behind a line known as the Electric Company because they “turned on the Juice,” he began breaking games open.

In 1973, Mr. Simpson became the first to rush for over 2,000 yards, breaking a record held by Jim Brown, and was named the N.F.L.’s most valuable player. In 1975, he led the American Football Conference in rushing and scoring. After nine seasons, he was traded to the San Francisco 49ers, his hometown team, and played his last two years with them. He retired in 1979 as the highest-paid player in the league, with a salary over $800,000, having scored 61 touchdowns and rushed for more than 11,000 yards in his career. He was inducted into the Pro Football Hall of Fame in 1985.

Mr. Simpson’s work as a network sports analyst overlapped with his football years. He was a color commentator for ABC from 1969 to 1977, and for NBC from 1978 to 1982. He rejoined ABC on “Monday Night Football” from 1983 to 1986.

Actor and Pitchman

And he had a parallel acting career. He appeared in some 30 films as well as television productions, including the mini-series “Roots” (1977) and the movies “The Towering Inferno” (1974), “Killer Force” (1976), “Cassandra Crossing” (1976), “Capricorn One” (1977), “Firepower” (1979) and others, including the comedy “The Naked Gun: From the Files of Police Squad” (1988) and its two sequels.

He did not pretend to be a serious actor. “I’m a realist,” he said. “No matter how many acting lessons I took, the public just wouldn’t buy me as Othello.”

Mr. Simpson was a congenial celebrity. He talked freely to reporters and fans, signed autographs, posed for pictures with children and was self-effacing in interviews, crediting his teammates and coaches, who clearly liked him. In an era of Black power displays, his only militancy was to crack heads on the gridiron.

His smiling, racially neutral image, easygoing manner and almost universal acceptance made him a perfect candidate for endorsements. Even before joining the N.F.L., he signed deals, including a three-year, $250,000 contract with Chevrolet. He later endorsed sporting goods, soft drinks, razor blades and other products.

In 1975, Hertz made him the first Black star of a national television advertising campaign. Memorable long-running commercials depicted him sprinting through airports and leaping over counters to get to a Hertz rental car. He earned millions, Hertz rentals shot up and the ads made O.J.’s face one of the most recognizable in America.

Mr. Simpson, in a way, wrote his own farewell on the day of his arrest. As he rode in the Bronco with a gun to his head, a friend, Robert Kardashian, released a handwritten letter to the public that he had left at home, expressing love for Ms. Simpson and denying that he killed her. “Don’t feel sorry for me,” he wrote. “I’ve had a great life, great friends. Please think of the real O.J. and not this lost person.”

Alex Traub contributed reporting.

An earlier version of this obituary referred incorrectly to the glove that was an important piece of evidence in Mr. Simpson’s murder trial. It was not a golf glove. The error was repeated in a picture caption.

How we handle corrections

Robert D. McFadden is a Times reporter who writes advance obituaries of notable people. More about Robert D. McFadden

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