ethical reasoning: a medical ethical reasoning model and its contributions to medical education

A medical ethical reasoning model and itscontributions to medical educationTsuen-Chiuan Tsai1,2 & Peter H Harasym3

OBJECTIVES Ethical reasoning in medicine isnot well understood and medical educatorsoften find it difficult to justify what and howthey teach and assess in medical ethics. Tofacilitate the development of moral values andprofessional conduct, a model of ethical rea-soning was created. The purposes of this paperare to describe the ethical reasoning model andto indicate how it can be used to foster moraland ethical behaviours.

METHODS The ethical reasoning model wascreated from information derived from twosources: (i) an examination of different ethicalmodels described in the literature, and (ii) think-aloud interviews with ethical experts in Taiwanand Canada. All the components and cognitivesteps used by experts in ethical decision makingwere extracted and categorised. Interview sub-jects consisted of 16 voluntary ethics experts. Theethical reasoning models reported in the litera-ture were divided into two groups according towhether they were justification-based or task-based models. Neither of the two types repre-sented the ‘whole picture’ of ethical reasoning inmedicine. This analysis enabled us to identify fiveuniversal cognitive steps and the gaps between‘logical decision’ and ‘action’.

RESULTS The think-aloud interviews verifiedthe multi-dimensional components or stepsused by experts when resolving ethical prob-lems. The resulting model, designated theMedical Ethical Reasoning (MER) Model,reflects interactions within three domains:medical and ethical knowledge; cognitivereasoning processes, and attitude.

CONCLUSIONS The MER Model accuratelyreflects how doctors resolve ethical dilemmasand is seen to be helpful in identifyingwhat and how educators should teach andassess in ethical reasoning. The model canalso serve as a communication framework forcurricular design. A ‘humane’ doctor is com-petent in providing quality, ethical patientcare. Making an appropriate ethical decisionis the foundation for subsequent ethicalbehaviours. By contrast with the abundantevidence cited in previous research describ-ing how doctors solve medical problems,there is little empirical evidence indicatinghow doctors make appropriate ethical deci-sions. Thus, the cognition of ethical reasoningin medicine is not well understood. Thispaper represents a step towards overcomingthis problem.

ethical reasoning

Medical Education 2010: 44: 864–873doi:10.1111/j.1365-2923.2010.03722.x

1Department of Paediatrics, E-Da Hospital, Jiau-Shu Tsuen,Yanchao Township, Kaohsiung County, Taiwan2Department of Chinese Medicine, I-Shou University College ofMedicine, Jiau-Shu Tsuen, Yanchao Township, Kaohsiung County,82445 Taiwan3Department of Health Care Administration, I-Shou UniversityCollege of Medicine, Jiau-Shu Tsuen, Yanchao Township,Kaohsiung County, Taiwan

Correspondence: Tsuen-Chiuan Tsai, MD, PhD, Vice-superintendent in E-Da Hospital and Associate Dean, I-ShouUniversity Medical College, 8, Yi-Da Road, Jiau-Shu Tsuen, Yan-Chau Shiang, Kaohsiung County, 82445 Taiwan.Tel: 00 886 7 615 1100 (ext 7013); Fax: 00 886 7 615 5750;E-mail: [email protected]

864 ª Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 864–873

INTRODUCTION

It has been widely believed that ethical decisionmaking is a complex process composed of manycomponents1,2 and cognitive steps.3,4 Further, teach-ers tend to teach according to their own professionalperspectives.5 Relevant studies on ethics are oftenpublished in a variety of professional journals,including those on medical education, psychology,philosophy, medicine, nursing, medical ethics andthe socio-behavioural sciences.6,7 The publishedresearch across disciplines tends to be difficult tosummarise because of the variety of investigativeapproaches, usage of different terms for similarconcepts and the variety of contexts in which ethicaldecisions are made. Therefore, teachers often find itdifficult to communicate learning objectives forteaching and curricular design, and to select appro-priate methods for teaching and assessing ethicalreasoning.

To enhance ethical education, it is necessary to usea model that delineates the required componentsand cognitive steps that reflect experts’ considerationson solving ethical problems and lead to successfulethical decisions. Using material sourced from aliterature review and think-aloud interviews con-ducted with ethical experts, this study established areasoning model that enables faculty members toenhance the quality of ethical education in medicine.The study received ethical approval. During datacollection, details of the study were explained to theparticipating volunteers to enable them to consent toparticipation.

Literature review

Using the key word ‘ethics’, combined with ‘reason-ing’, ‘problem solving’ and ‘cognition’, along with‘model’, ‘strategies’ and ‘steps’, the literature searchwas intended to bring up proposed ethical reasoningmodels from a variety of fields. Each model wasevaluated relative to its application in medicine, andthe components and cognitive steps used in ethicaldecision making were identified. In addition, thestudy identified the weaknesses and strengths of eachmodel, plus the advantages offered to medicaleducators.

The ethical reasoning models reported in the liter-ature were divided into two groups according towhether they were justification-based or task-based.A justification-based model indicates the moral andethical beliefs or values that are chosen from among

several competing values to result in an ethicaldecision and subsequent behaviours.2,8–10 Thetask-based model focuses on the cognitiveprocesses that enhance ethical decisions.1,3,4,11,12

Many of the models are general in scope (e.g.morality) and only a few are specific to the medicalprofession. In total, we found seven justification-based and five task-based models; these are summar-ised in Table 1.

Justification-based models

Kohlberg8 and Gilligan9 proposed several develop-ment stages of morality. Kohlberg’s stage theory8 hasbeen successfully used to develop measurement tools(e.g. the Defining Issues Test).3 Gilligan added theconcerns of women and conflicts of interest9 toKohlberg’s stage theory.8 However, the developmentalstages are too simplistic and assume that cognitivereasoning can be consciously applied in a hierarchicalmanner while emphasising basic principles of justice.Furthermore, there is neither empirical support forthe validity of the developmental stages, nor evidencefor the conscious application of cognitive reasoning ina hierarchical manner when making an ethical deci-sion.13 Van Hoose2 presented the ethical orientationmodel in counselling based on Kohlberg’s stagetheory.9 Teleological theory (also named ‘utilitarian-ism’ or ‘consequentialism’) decrees that a doctor’sethical decisions are judged according to the outcomesor consequences for the patient,14 whereas, in deon-tological theory, a doctor’s actions are judged accord-ing to how well the behaviours conform to a set ofduties, rules or responsibilities.15 Rawlsianism’s16 ‘jus-tice as fairness’ and Daniels’17 ‘reflective equilibriumapproaches’ drew attention to beliefs on variousreflective levels (particular intuitions, moral princi-ples, abstract theories) and sought to establish coher-ence among them when judging a decision on anethical or moral problem. However, such beliefrevisions can be ‘unreliable’, and DePaul’s ‘Balanceand Refinement’18 sought to correct such unreliabilityby inquiring into the rationality and warrant of adecision. Finally, Evans described the ‘belief–bias dualeffect’ of reasoning (i.e. logic- and belief-based posi-tions) to highlight the discrepancies between optimalethical and actual ethical behaviours.10 Unfortunately,none of the above models represent an entire pictureof the components or cognitive steps that mightindicate how doctors solve clinical ethical problems.

Task-based models

Rest’s ‘four-component model’3 divides moralreasoning into four hierarchical steps (i.e. moral

ª Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 864–873 865

Development of a medical ethical reasoning model

sensitivity, moral judgement, moral commitment andmoral action). Based on this model, several mea-surement tools or instruments have been developedand used in ethical research and to measurestudents’ ethical competency (e.g. the Dental EthicalSensitivity Test,19 the Dental Ethical Reasoning andJudgement Test20 and the Professional Role Orien-tation Inventory21). Jonsen et al.’s ‘four-box meth-od’1 has been used to examine doctors’ analyses ofthe four quadrants of ethical considerations todetermine if relevant information was comprehen-sively utilised in optimal patient care that includedthe resolution of ethical dilemmas. This model hasalso been used to design the Qualitative OutcomeAssessment (QOA) instrument.22 Unfortunately, theQOA does not offer guidelines for making correctethical decisions, or guidelines to resolve specific

problems.23 Snyder and Mirr’s 10-step,4 Brody’s five-step12 and the Josephson Institute of Ethics seven-step11 models break the complexity of ethicalreasoning into a series of tasks (or steps) that mustbe undertaken to arrive at an ethical decision. Thesemodels require the user to generate a set ofhypotheses (i.e. similar to the rank-ordered processof hypothetical-deductive reasoning) and to usethem to select the optimal or correct ethicaldecision.24 Unfortunately, there is no empiricalevidence to validate the suggestion that subjects usehypothetical-deductive reasoning and follow cogni-tive steps to solve ethical problems. For example,Brody,12 in his 5-step model, suggested identifyingproblems before gathering information, whereasBebeau stated that people may gather informationbefore they recognise a problem.25

Table 1 Summary of justification systems and reasoning tasks underlying different ethical reasoning models

Model Content

Justification-based models

Stage theory: Kohlberg,8

Gilligan9

(1) Pre-conventional; (2) conventional; (3) post-conventional

Care theory

Ethical orientation model:

Van Hoose 2

(1) Punishment; (2) institutional; (3) societal; (4) individual; (5) principle

Teleological ⁄ consequential

(Utilitarianism)20

Based on the outcomes or consequences for the patient

Deontology (Kantianism)15 Based on the relevant duties, rules and responsibilities

Reflective equilibrium approaches:

Rawls 16 and Daniels17

Testing all the ‘beliefs’ by: (1) liberty principle (an equal right to the most extensive scheme of basic

liberties); (2) difference principle (social and economic inequalities are arranged to the greatest benefit

of the least advantaged)

Balance and refinement: DePaul Moral inquiry on: rationality (whether the subject is doing all he or she could to ensure the truth of

beliefs); warrant (whatever feature must be possessed by a true belief to yield knowledge)

Belief–bias dual effect: Evans10 (1) Logic-based processes; (2) belief-based processes

Task-based models

Four-component model for

moral reasoning: Rest3(1) Moral sensitivity (identifying conflict, interested parties, consequences and obligations); (2) moral

judgement (the justification process); (3) moral commitment; (4) moral action

Four-box method: Jonsen et al.1 (1) Medical indications; (2) patient preferences; (3) quality of life; (4) contextual features

10 Steps: Snyder & Mirr 4 (1) Review the situation; (2) gather additional information; (3) identify personal and professional values;

(4) identify values of key persons; (5) identify conflicts in values; (6) determine who should decide;

(7) identify the range of actions with their anticipated outcomes; (8) make a decision;

(9) take action; (10) evaluate the outcomes

Seven Steps: Josephson

Institute of Ethics11

(1) Stop and think; (2) develop options; (3) clarify short- and long-term goals; (4) determine facts to

support an intelligent choice; (5) consider consequences; (6) make a decision; (7) monitor and modify

Five Steps: Brody12 (1) Perceive the problem and take action; (2) list alternative solutions; (3) analyse the strengths and

weaknesses of each solution; (4) select alternatives with the highest value; (5) make an ethically

correct choice


T-C Tsai & P H Harasym

METHODS

In an effort to understand what, how and why doctorsmake ethical decisions, think-aloud interviews wereconsidered the best method to extract and diagramthe thoughts behind and sequencing of each com-ponent. Fifteen clinical vignettes involving ethicaldilemmas (see Appendix S1 [online] for a list ofthese ethical dilemmas) were used as stimuli. Inter-view subjects were initially provided with minimalinformation about the dilemma and were allowed toask for more information until they reached anethical decision. (Appendix S2 shows a samplevignette and its initial presentation.) Intervieweeswere encouraged to verbalise, without interruption,whatever thoughts came to mind. An ethical dilemmaor issue was characterised by the presence of con-flicting ethical principles, or a conflict between therights or obligations of the interested parties. Thethink-aloud interview was restricted to a length of1 hour to minimise fatigue and obtain the maximumquality of input from each subject. The interviewschedule generated 128 doctor–vignette encountersinvolving 15 cases (90 encounters with Taiwanesedoctors and 38 with Canadians). During the 1-hourinterview, each subject addressed an average of eightvignettes (mean = 7.9, standard deviation [SD] 2.1).For two subjects, only four vignettes (of eight) werecounted as a result of technical problems. Themaximum number of vignettes addressed (by twosubjects) was 11.

The interviews were audiotaped and transcribedverbatim. Using the immersion and crystallisationapproach, the written protocols were then indepen-dently analysed by two coding experts. The conceptsor facts, knowledge, rationale and strategies appliedby the subjects to make ethical decisions werecategorised using a framework comprising a series ofheadings: ‘knowledge’; ‘skill’; ‘attitude’, and‘justification’. The above components were furtherdiagrammed to determine the sequence of theirappearance. This sequencing of components isreflected in the Medical Ethical Reasoning (MER)Model.

The subjects in this study represented a conveniencesample of voluntary ethical experts. The inclusioncriteria required participants to be doctors and tohave served as ethics consultants, members of ethicscommittees or teachers of ethics courses for at least2 years. An ‘expert’ was defined as someone whowould make ethical decisions and adopt ethicalbehaviours consistent with contemporary standards.

RESULTS

In order to develop the MER Model, both thecomponents of the justification-based and the steps ofthe task-based models were encapsulated. From thejustification-based models we included such compo-nents as doctor knowledge (clinical and ethical),7,25

personal social and moral values,2 past experiences,contextual factors and the system of justification.Among the task-based models, steps such as problemidentification, information gathering, decision mak-ing, planning and action appeared to be bothuniversal and to hallmark both clinical and ethicaldecision making; thus we also encapsulated these intothe MER Model.

Interviewees comprised 12 expert participants inTaiwan and four in Canada. These included ninemen and three women, aged 45.6 ± 6.8 years, inTaiwan, and two men and two women, aged50 ± 13.1 years, in Canada.

The experts always began with information gather-ing, with or without verbalising the correspondingethical problems. This was followed by decisionmaking and, finally, by the production of an actionplan. Two-thirds of the experts described the ethicalproblems only when asked to. In terms of theinformation elicited by the experts, medical concernsor considerations were always raised first when asituation was unclear, followed by patient preferences.In the vignette involving a pregnant woman who hasleukaemia and refuses chemotherapy, the expertsalways began by asking: ‘How advanced is the disease?’The discourse would then proceed roughly as follows:

Interviewer: ‘The cancer is acute lymphocyticleukaemia.’

Expert: ‘What is the probability that the foetus will beharmed by the therapy?’

Interviewer: ‘High.’

Expert: ‘What reasons does she [the patient] give forrefusing therapy?’ etc.

(Appendix S3 shows the concept map that reflects thesequence of events.)

The ethical theories of justification applied by theexperts included utilitarianism (i.e. judgement basedon the outcomes or consequences for the patient),14

natural law theory (i.e. content set by nature),



principlism (i.e. ‘filling in’ principles to increase theirrelevance to a given situation), and reflective equi-librium and balancing (i.e. determining the moralweight of competing principles and assessing whichtakes priority).

Following inquiry into the health status of the patient,the ‘patient’s preference’ was the expert’s next con-cern: ‘Just like the end-of-life issue, the abortion issueas well… is inherent within patient autonomy.’ Oncethe expert had acquired a clear understanding of thenature of the patient’s health and the ethical dilemma,he or she proceeded to balance the conflict of interestbetween the public and individual concerns; in thiscontext the experts demonstrated a tendency to placethe patient’s needs before any considerations per-taining to the cost and availability of health resources.This sequence of events was also present in other cases.For example, in the vignette involving a subject withbrain death, in which the patient’s mourning parentswere described as having difficulty in accepting thewithdrawal of life support, one expert responded: ‘Iwould allow a reasonable period of grieving…although… it is a sort of waste of resources.’

Prior similar encounters also had an effect onexpert behaviours and the decisions made. It emergedthat 62 of the 90 (68.9%) vignettes covered byTaiwanese doctors and 22 of the 38 (57.9%) vignettestackled by Canadian doctors bore similarities to

previous events experienced by the doctors inquestion. This study found that similar prior experi-ences directed decisions, even when the doctor wasconscious of a discrepancy between the guidingethical principle and the patient’s or family’s desire.The latter on occasion was given priority over theethical principle. For example, in dealing with thedisclosure of bad news, the Taiwanese experts werereluctant to state the truth directly to the patient. Oneexpert said: ‘We once broke bad news to a patient whoimmediately left our hospital and his family filed acomplaint with the hospital superintendent.Although I did the right thing, it brought unwanteddifficulties and unhappy experiences.’

This doctor continued: ‘Theoretically, I should fullydisclose the truth to the patient; however, we cannotbecause of past consequences.’

The gap between ‘knowing’ and ‘doing’ confirmsEvans’ model of the ‘belief–bias dual effect’.10

The MER Model: a reasoning model for ethicseducation

Based on the findings derived from interviews andthe literature review, the MER Model (Fig. 1) wasdeveloped. This model comprehensively reflectsthe cognitive process, the essential componentsinvolved in doctors’ ethical reasoning and the gap

Ethical dilemma

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Tasks for clinical and ethical decision making

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4 Observed clinical behaviours

Belief/value/character/moral development Conflicts

Involved parties Consequences

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Figure 1 Diagram of the Medical Ethical Reasoning Model



between the ‘logical decision process’ and the finalactions. The new model is seen to be valuable forfacilitating communication among teachers andlearners, for identifying possible areas of studentdifficulty in learning, for designing curricular mate-rials and for selecting appropriate teaching strategies.

The MER Model first identifies the essential compo-nents in ethical decision making, including thedoctor’s knowledge (clinical and ethical),4,7 problem-solving abilities, personal social and moral values,2

past experiences, contextual factors, and the systemof justification underlying the conduct of ethicalbehaviours. The model also represents interplayamong the components. The above components werethen categorised into three domains:

1 knowledge: medical knowledge pertaining to theintervention and relevant ethical knowledgeinvolving the specific medical practice;

2 cognitive reasoning strategy, including problemidentification, information gathering, decisionmaking, planning and action, and

3 attitudes: the justification for the use of appro-priate principles, laws or values to rationalise adecision or to modify actions.

The following paragraphs describe each domain.

Ethical knowledge

As in medical problem solving, a successful ethi-cal decision requires sound medical and ethicalknowledge that can be retrieved and appropriatelyapplied to meet the patient’s needs. Ethical knowl-edge is composed of knowledge of legal regulations,professional codes, ethical theory (normative ordescriptive), and principles derived from socio-cultural values. Legal regulations are defined by lawsthat are dependent on interpretation, clarificationand precedence. Ethics-related laws define the min-imal performance level of medical ethical behaviours,but medical ethical decisions should be well above‘minimal’ requirements. Given that ethical behav-iours are based on national and regional laws, theremay be variations in ethical acceptability or standardsthat reflect differences in socio-cultural and politicalsituations among different areas and regions. Thesevariations are sometimes complicated by differencesin individual views of the laws, which, in turn,influence the decisions made. Therefore, there maybe variations in decision making that are dependenton an individual’s understanding of the law, thenature of the medical problem and the socio-cul-tural ⁄ political situation.

Cognitive reasoning skill

This study found the ‘cognitive skill’ domain of theMER Model to be composed of four steps in sequence:

1 problem identification and informationgathering;

2 decision making;3 planning, and4 action.

The steps of ‘problem identification’ and ‘informa-tion gathering’ were merged as a single step becausethey were not found to occur in a fixed sequence.The way doctors collect information is dependenton the doctor’s knowledge structure, and experienceof and attitudes towards a particular disease, patientor ethical dilemma. However, the ‘true’ ethicalreasoning strategies applied by doctors in practiceremain locked in their individual ‘black boxes’ asthey are inherently difficult to extract and cannotbe observed directly.

Attitudes

Based on the relevant information, a ‘logic-baseddecision’ can be concluded by considering thedifferent perspectives of all the parties involved,minimising potential conflicts among stakeholdersand between competing principles, and evaluatingthe consequences.26 The ‘logic-based decision’ wasthen modified by the system of justification, includingprobabilities, theories, rules and principles, profes-sional codes, beliefs, values, guidelines, conse-quences, comparable cases and prior experiences.15

In the real world, the justification is actually influ-enced by the many individual or contextual factorsthat affect the decision maker at (un)conscious levels(e.g. the patient’s or family member’s appearance,speech, behaviour, socio-economic status, educationlevel, anxieties and prejudices, etc.). Using a medicalmetaphor, the ‘justification system’ is the ‘patho-physiology’ of ethical reasoning, which determinesthe ethical issues of right and wrong or better andworse. The domain of ‘attitudes’ refers to the valuesor beliefs governing the ‘justification’, which explainsthe gap between the ‘logic-based decision’ and the‘final actions’.

DISCUSSION

A thorough review was completed of ethical modelsin a variety of disciplines. Based upon analyses andevaluation of the components and cognitive



procedures, a basic model was created to reflectethical problem solving in medicine. To refine thismodel, the think-aloud interview strategy was used toconfirm and accordingly alter the initial model. Therefined theoretical framework was designated theMedical Ethical Reasoning Model.

By contrast with medical reasoning, for which anabundance of research evidence has been citedduring the past 30 years,24 ethical reasoning is notwell understood because the literature, although vast,remains dispersed. Thus, it is worthwhile comparingethical and medical reasoning based on the pre-liminary results in this research. The following aspectswere summarised for the purposes of comparing thetwo different types of reasoning: the problem

encountered; the diagnosis or decision; commonality;information and data; planning and management;outcome indicator, and the foundation for justifica-tion (Table 2).

Given the increased complexity of medical technol-ogy and health care, the challenges involved inproviding quality care that engages with ethicalconsiderations are now greater than ever. In thejustification of ‘action’, the following concepts inpatient care, which have emerged in this era, must behighlighted as important.

1 Quality medical care should strive to achieve abalance between the needs of different stake-holders who may have conflicting demands (e.g.

Table 2 The tasks or items involving problem solving in medicine: comparison between medical and ethical problem solving

Aspect Medical problem solving Ethical problem solving

Problem encountered Illness (e.g. shortness of breath, chest pain) Dilemma (e.g. patient requests a futile treatment)

Variability of diagnosis

or decision

The number of diseases in medicine is vast

(c. 10 000)

The number of ethical decisions is relatively small

(estimated to be < 100)

Commonality More complex and learned after entering medical

school: dealing with a disease or syndrome

(e.g. pneumonia, asthma)

Confronted in daily life, learned as soon as early

childhood: relatively simple, not much beyond the

scope of ‘which opinion, principle or law to accept,

what action to take, and how to best serve the needs

of the patient, family and community’

Information and data Clinical presentation and laboratory findings

(e.g. coughing for 2 weeks, leukocytosis,

pneumonic patch on chest X-ray)

Medical indication*

Patient preference*

Quality of life*

Contextual features*

Planning and

management

Medical intervention (e.g. parenteral antibiotics) Action based on the ethical plan (e.g. withholding life

support and providing emotional support)

Outcome indicator Mortality, morbidity, quality of life Individual (physical or psychological) interest, family

and community (socio-economic) interest

Foundation for

justification

�Professional craft knowledge�Propositional (empirically based) knowledge§Evidence-based medicine

Pathophysiology

Personal value

Personal experience

Ethical theory or principles, rights, consequences,

comparable cases, professional guidelines, and

conscientious practice

Experience

Personal values

* Four-box method of ethical reasoning: medical indications, quality of life, patient preferences and context (Jonsen et al.1)� Professional craft knowledge: arises from the rigorous appraisal and processing of professional experience25

� Propositional knowledge: derived from research (e.g. random control trials, meta-analyses, empirical and experiential, pathophysiology)and theory25

§ Evidence-based medicine is a strategy designed to ensure that potentially competing goals of policymakers, practitioners and patients canbe mutually satisfied. It seeks to draw research and practice together. Guidelines and protocols are based on evidence of the bestmanagement, clarity and ease of use



pursuing the greatest benefit to patients at thelowest risk and the lowest cost to the health caresystem).

2 Quality health care must incorporate advancesin evidence-based medicine and patient prefer-ences of outcomes with the doctor’s clinicalintuition.27

3 Globalisation, accompanied by the migration ofdoctors, patients and diseases, is now a trend.Quality health care should take into consider-ation both global standardisation and flexibilityacross different cultural and socio-economiccontexts.

The MER Model provides a framework to helpteachers and learners communicate what should betaught or assessed when resolving a specific ethicalproblem. There are three components to ethicalproblem solving (knowledge, attitude and skills).Although there is a natural tendency for students tofocus on the patient’s medical problem, there is alsoa need to direct students to ethical concerns. To thisend, it is necessary to advance students’ awareness ofall three components. Currently, the most commonfocus is on advancing the ethical knowledge anddecision-making capabilities of students. However, itis also important to sensitise students to their ownpersonal values and biases while retaining theirmindfulness of the resources available, the wishes ofthe patient and his or her family, and, whennecessary, the need to defuse volatile situations(contextual factors). Ethical reasoning appears toextend beyond clinical reasoning because inappro-priate attitudes (e.g. emotions and biases) mayprevent the identification of optimal ethicalsolutions.

To facilitate effective teaching and learning ofmedical ethics, this study suggests the use of the MERModel and attends to the components or steps ofethics reasoning. The model can help teachers andlearners communicate what should be taught orassessed. Based on the model, teachers can identifydeficiencies in students’ ethical competencies andcan decide where and how students may havedeviated. Further, the model can help researchers tostudy the ethical development of expertise throughin-depth comparisons of novices and experts, byidentifying the research focus of knowledgestructures, cognitive strategies and attitudes thatunderlie ethical behaviours.

Note that individuals are more likely to evaluate theirdecisions, behaviours or treatments and less likely toevaluate their personal values. Thus, when teaching

there is a need to help students become aware oftheir values and biases. Individual feedback can begiven by teachers of small-group sessions throughanalyses of the consequences of choices or decisionsmade. In other words, an individual’s ability to ‘beethical’ must grow through resolving and grapplingwith new clinical challenges. Thus, ‘being ethical’ is aprocess of growth in understanding (standards,principles and values), perception (what is seen basedon what we know and value) and creative problemsolving (decisions and behaviours) that leads to arespect for the interests of individuals, the professionand society.

Each of the components identified in the MER Modelcan be taught using appropriate teaching strategies.For example, didactic lectures and reading are usefulfor helping students accumulate relevant medicalethical knowledge; small-group discussions, problem-based learning and case studies are helpful inproviding clinical experiences that enhance ethicalproblem-solving capabilities, and role-playing, shar-ing and social services can be used to develop orshape personal beliefs and values. By using the MERModel, teachers in different professions cancommunicate and collaborate in advancing ethicalcompetency in students.

Traditionally, ethics education has focused on thedomain of ‘knowledge’ and has assumed that studentswill be able to properly apply or use this knowledgewithin a given clinical case. Today, there is greaterawareness of the need to develop appropriate cognitiveskills and attitudes. However, changing an individual’sattitudes is difficult, takes time and is challenging toformally evaluate. These attitudes and values reflectcharacteristics of humanity, empathy, curiosity,respect, sensitivity, trustworthiness, honesty, compas-sion, caring and humanity. The development ofproper attitudes is not instigated by lecturing (i.e.affirming, declaring, claiming, telling or stating),but by educating (i.e. questioning, challenging,inspiring, showing, motivating, problem solving andreflecting).

We stress the importance of creatively teachingethical knowledge, appropriate cognitive skills, andcorrect values and attitudes. In addition, it is impor-tant to give learners ample opportunities to practiseethical problem solving and to receive feedback, andto encourage reflection.

In summary, this study provides a new modelindicating the multi-dimensional componentsunderlying ethical reasoning. Using the model as an



educational framework can enhance the effectiveteaching and learning of medical ethics. We believethat the MER Model is a heuristic device that is usefulfor guiding student learning in the early stages ofknowledge growth, attitude refinement and skilldevelopment. If emotional or subconscious reactionsto patients and families are ignored or fail to beidentified in the teaching situation, students willnot realise how much these affect decision makingin real life. Further research will field-test the effec-tiveness of this model in teaching and assessingmedical ethical reasoning and its validity forcurricular design.

Limitations

In this study, paper cases were used to facilitate anenquiry into the knowledge structure and cognitiveprocesses underlying ethical reasoning. The presen-tation of paper cases is inevitably artificial because itremoves all the real-life factors that influence deci-sion making, often at (un)conscious levels. In reallife, emotional or subconscious reactions to patientsand families are important. This component iscovered in the MER Model generically as a contextualfactor, but is not detailed.

It is also important to point out that the MER Modelhas not been empirically validated. We believe thatthe model is superior within the field of medicaleducation because it was created using two strategies.The first of these involved the examination andabstraction of relevant components from differentethical models described in the literature acrossvarious disciplines (a basic foundation upon whichthe initial MER Model was created). The secondinvolved the improving and validating of the modelusing components and cognitive procedures ab-stracted from the think-aloud data obtained fromethical experts. Thus, we believe the MER Modelcontains all the relevant components and cognitivesteps found to be necessary in and reflective of themedical ethical experts’ behaviours and deemed tobe useful in the initial stages of educating medicalstudents.

Contributors: T-CT conceived the study, contributed to thestudy design, prepared the submission to the institutionalreview board, constructed the clinical vignettes, collected,analysed and interpreted the data, trained the interviewers,developed the Medical Ethical Reasoning Model and wrotethe manuscript. PHH contributed to the study design,provided supervision and administrative, technical andmaterial support throughout the study, supervised the

Canadian interviewers, and contributed to the criticalrevision of the manuscript.Acknowledgements: the authors express appreciation forthe assistance of Drs Sylvain Coderre, Kevin McLaughlinand Tyrone L Donnon of the University of Calgary, Calgary,Alberta.Funding: this research was supported by a grant (NSC96-2516-S-038-005-MY2) from the National Science Council inTaiwan.Conflicts of interest: none.

Ethical approval: this study was approved by theinstitutional review boards of the University of Calgary,Calgary, Alberta and National Cheng Kung UniversityMedical College, Tainan, Taiwan.

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SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article.

Appendix S1. List of 15 clinical vignettes involving ethicaldilemmas.

Appendix S2. Sample case 1. A woman in a vegetative stateneeds an emergency operation for acute appendicitis.

Appendix S3. A sample concept map on the case of apregnant woman with leukaemia.

Please note: Wiley-Blackwell are not responsible for thecontent or functionality of any supporting materials sup-plied by the authors. Any queries (other than for missingmaterial) should be directed to the corresponding authorfor the article.

Received 6 September 2009; editorial comments to authors 16November 2009, 17 February 2010; accepted for publication 17March 2010



ethical reasoning: a medical ethical reasoning model and its contributions to medical education

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