DONNIE J.

SELF

A STUDY OF THE FOUNDATIONS OF ETHICAL

DECISION-MAKING OF PHYSICIANS

ABSTRACT. A study of physicians and medical students was conducted to determine

the various philosophical positions they hold with respect to ethical decision-making in
medicine and their epistemological presuppositions in relationship to the subjective-objective
controversy in value theory. The study revealed that most physicians and medical students
tend to be objectivists in value theory, i.e., believe that value judgements are knowledge
claims capable of being true or false and are expressions of moral requirements and norma-
tive imperatives emanating from an external value structure or moral order in the world,
but that most physicians and medical students are inconsistent in the philosophical founda-
tions of their medical ethical decision-making, i.e., in decision-making regarding values they
tend to hold beliefs which are incompatible with other beliefs they hold about values.
The study also revealed that most physicians and medical students think more emphasis
should be placed upon medical ethics in medical education.

Key words: Ethical decision-making, Epistemological presuppositions, Subjective-objective

distinction, Consistency, Value theory.

1. INTRODUCTION

The following study is an attempt to identify and understand better the philo-
sophical positions which physicians and medical students at various stages in
their careers, knowingly or unknowingly, utilize in medical ethical decision-
making. Of special interest are the various positions in the subjective-objective
controversy in value theory, i.e., whether value judgements are purely personal,
private expressions of one's own opinion and inner-subjective feelings or whether
value judgements are expressions o f moral requirements and normative impera-
tives emanating from an external value structure or moral order in the world.
This will be elaborated in more detail later.
There has been a significant increase in interest in medical ethical decision-
making during the past few years. However, there has been a noticeable lack
o f empirical data gathered on the issue. Indeed a search o f the holdings o f
the National Library of Medicine revealed that while numerous conceptual
discussions about ethical decision-making in medicine have been written, virtually
no studies o f actual data gathered on the issue have been reported. This study
was undertaken with the objective o f identifying the philosophical stances
and epistemological presuppositions of physicians with respect to medical
ethical decision-making. The study examines the following hypotheses: (1) Most
physicians tend to be objectivist in value theory, i.e., believe that value judge-
ments are knowledge claims capable o f being true or false and are expressions o f

Theoretical Medicine 4 (1983) 57-69. 0167-9902/83/0041-0057501.30.

Copyright © 1983 by D. Reidel Publishing Company.
58 DONNIE J. SELF

moral requirements and normative imperatives emanating from an external value

structure or moral order in the world; (2) Most physicians are inconsistent in
the philosophical foundations of their medical ethical decision-making regardless
of whichever position they tend to hold on the subjective-objective issue in value
theory.
The first hypothesis relates medicine to a fundamental issue in moral philos-
ophy - namely, the epistemological status of value language and ultimately the
ontological status of values. Although value language has been analyzed and
explicated in many ways the watershed in value theory comes in the subjective-
objective controversy. It is here that the status of values is determined. Indeed
E. M. Adams notes:

The thesis that value judgements in general and moral judgements in particular have no
objective ground, that they are subjective and private, needs to be thoroughly explored and
assessed. If it is a sound thesis, then we must face up to the consequences. If it is a false
thesis, we must look for ways to regain faith in the objectivity of values. Herein lies the
central task of moral philosophy of our age.1

The second hypothesis relates medicine to one of the most philosophically

desirable characteristics - namely, consistency. Whatever position one holds
it must be internalAy consistent in order to be a logically viable position and
ought to be applied consistently to a wide range of circumstances. This hypoth-
esis contends that in decision-making about values physicians tend to hold
beliefs which are incompatible with other beliefs they hold about values.

2. METHOD

The study consisted of gathering, analyzing and interpreting data gathered from
questionnaires submitted to 853 physicians and 288 medical students at a major
medical center in the United States. This included senior staff, house staff
and the student body. The questionnaire consisted of one page containing
10 questions to be answered affirmatively or negatively and several biographical
designations. The questions were constructed in such a way that there were
three questions relating to each of the three possible positions in the subjectiye-
objective issue (elaborated in Section 4 below) and one general question relating
to the perceived need for more emphasis on medical ethics in medical education.
The questionnaire contained no controversial questions such as questions which
would elicit the respondent's feelings about issues of abortion, euthanasia, etc.
Rather the study was designed to focus on theoretical issues in ethics. However,
the questions were carefully constructed in jargon-free language so as to require
no theoretical understanding of philosophical concepts such as subjectivism
and objectivism. Indeed the terms 'subjective' and 'objective' did not even
 ETHICAL DECISION-MAKING OF PHYSICIANS 59

appear on the questionnaire. The questions were constructed in pairs in order

to check for consistency in the responses. For example, questions one and eight
were essentially the same question in different words. The instrument was
developed specifically for this study and had not been utilized in any other
study.

3. RESULTS

A total of 261 responses constituted a 22.9% return. The low percent return is
accounted for in part by the fact that the study was an eight week summer
project with time constrains which did not permit follow-up mailing, reminders,
second or third questionnaires, etc. The surveyed population consisted of 43
(16.0%) females and 218 (84.0%) males with an age range from 21 to 66 years
old. Classification of the respondents indicated 38.4% senior staff, 18.4% house
staff and 43.2% students. There were 29 medical specialties and sub-specialties
represented as well as sophomore, junior and senior medical students. The
religious background of the surveyed population consisted of 68.0% Protestant,
9.0% Catholic, 15.2% Jewish and 7.8% others. The data gathered from the
questionnaires are shown in Table I and II. Table III presents a comparison of
the means of the sets of questions relating to each of the positions on the
subjective-objective issue. Table I V - V I present the data regarding the consistency
of the responses. Analysis of the data confirms both of the hypotheses.

TABLE I
Physician decision-making data

Number of Number of
affirmative negative
Questions responses Percentage responses Percentage

1. In difficult situations do you

generally seek the solution
which offers the greatest good
for all concerned - patient,
family, medical staff, etc. 218 87.20% 32 12.80%
2. In medical decisions involving
ethical questions do you think
that there are right answers
and wrong answers? 132 52.17% 121 47.83%
3. Do you think that values such as
the rightness or wrongnessof an
act are determined by the facts
of the context? 210 85.71% 35 14.29%
60 D O N N I E J. SELF

Table I (continued)

Number of Number of
affirmative negative
Questions responses Percentage responses Percentage

4. In complex medical ethical cases

can one sometimes have ethical
obligations without being aware
of them or realizing that they
are encumbent upon one? 244 94.94% 13 5.06%
5. Do you think that certain acts are
right and others wrong regardless
of the situation? 123 48.24% 132 51.76%
6. Do you think that rightness or
wrongness of an act is basically
determined by its consequences? 85 33.33% 170 66.67%
7. Do you think that in ethical decision-
making in medicine, values are relative
to the person making the judgement? 161 66.53% 81 33.47%
8. Do you always seek the best welfare
of the patient regardless of what
effect it has on the family, medical
staff or others? 108 42.86% 144 57.14%
9. Do you think that value judgements
about medical ethical situations can
be either true or false? 89 37.08% 151 62.92%
10. Should more emphasis be placed
upon medical ethics in medical
education? 211 83.07% 43 16,93%

TABLE II
Biographical data

Biographical Percent of
characteristic respondents

Senior Staff 38.4

House Staff 18.4
Student 43,2
Male 84.0
Female 16,0
Protestant 68,0
Catholic 9.0
Jewish 15.2
Other 7.8
 ETHICAL DECISION-MAKING OF PHYSICIANS 61

T A B L E III
Comparison o f set m e a n s

Supportive
Question Response required Response Supportive response
Position number to support position received m e a n o f set

Objectivist 2 yes 52.17%

Objectivist 3 yes 85.71% 77.60%
Objectivist 4 yes 94.94%

Part. Obj. -
Part. Sub, 1 yes 87.20%
Part. Obj, --
Part, Sub. 6 yes 33.33% 59.22%
Part. Obj. -
Part. Sub. 8 no 57.14%

Subjectivist 5 no 51.76%
Subjectivist 7 yes 66.53% 60.40%
Subjectivist 9 no 62.92%

T A B L E IV
G r o u p consistency comparison over-all

Actual group
response received
Response required Majority actual
Question Number for consistency Yes No group responses

2 yes no 132 121 yes

Pair or
9 yes no 89 151 no
3 yes no 210 35 yes
Pair or
7 yes no 161 81 yes
1 yes no 218 32 yes
Pair or
8 no yes 108 144 no
4 yes no 244 13 yes
Pair or
5 yes no 123 132 no
5 yes no 123 132 no
Pair or
6 no yes 85 170 no
62 D O N N I E J. S E L F

TABLE V
Summary of inconsistent responses to question pairs

Numbers of pairs Number of

answered inconsistently respondents

0 24- 9.23%
1 68 - 26.15%
2 69 - 26.54%
3 71 - 27.31%
4 21- 8.08%
5 7- 2.69%

TABLE VI
Individual consistency comparison

Question Response required Individual consistent Individual inconsistent

number for consistency responses to pair responses to pair

2 yes no
Pair or 164 - 69.49% 72 - 30.51%
9 yes no
3 yes no
Pair or 98 - 42.42% 133 - 57.58%
7 no yes
1 yes no
Pair or 155 - 63.01% 91 - 36.99%
8 no yes
4 yes no
Pair or 125 - 49.60% 127 - 50.40%
5 yes no
5 yes no
Pair or 134 - 52.96% 119 - 47.04%
6 no yes

4. B A C K G R O U N D I N F O R M A T I O N

A b r i e f c o n s i d e r a t i o n o f t h e subjective-objective issue in value t h e o r y m i g h t b e

h e l p f u l in u n d e r s t a n d i n g t h e results o f t h e survey. All ethical decisions are,
i m p l i c i t l y o r e x p l i c i t l y , b a s e d u p o n o n e o f t h r e e possible p o s i t i o n s in value
t h e o r y - n a m e l y , c o m p l e t e subjectivism, partial subjectivism-partial o b j e c t i v i s m ,
 ETHICAL DECISION-MAKING OF PHYSICIANS 63

and complete objectivism. It is from these positions that the subjective-objective

controversy arises in ethics. This issue has been extensively elaborated elsewhere
with arguments for and against the adequacy of the altervative positions. 2
Those arguments need not be repeated. I will only summarize briefly a statement
of the alternative positions here.
The three positions are determined by their stands on value experience and
value language. But first perhaps the distinction between value experience and
value language needs to be clarified. Value experience is the affective-conative
state that one experiences or undergoes when in evaluative or emotive circum-
stances. In contrast, value language is the language or terminology used to
describe, report, or express value experience. One can be a subjectivist with
regard to value experience and still be either a subjectivist or an objectivist
with regard to value language. On one extreme is what is known as pure or
complete subjectivism. Existentialism is the most popular paradigm of this
position. Subjectivism is subjective with respect to both value experience and
value language. It holds that value experience is not cognitive, not epistemic
or knowledge-yielding, and not the discernment of a value structure in reality.
But also, value language as distinct from value experience is held to be subjective
in that value judgements are held to make no truth claim at all, and so cannot
be true or false. Pure subjectivism maintains that moral judgements are expres-
sions of emotions, preferences, or decisions and are not cognitively significant;
i.e., they literally do not make a knowledge claim. Value judgements are not
even of or about value experience. They are merely expressions of emotions or
preferences.
A middle position is partially subjective and partially objective. It is subjec-
tive with respect to value experience only. It is objective with respect to value
language. Utilitarianism is the most widely known paradigm of this position.
The middle position holds that value judgements are of and about value experi-
ence in a cognitively significant manner such that they do make knowledge
claims which can be confirmed to be true or false. Value language serves a
definite function. It makes truth claims about value experience and expresses
and describes value experience. Yet it does not express the semantic content or
meaning of value experience for this middle position denies that value experience
is intentional or has a semantic content. Value language is not grounded to the
world through experience because value experience itself is subjective and
not a discernment of an external objective value structure or moral order in the
world. It has no semantic connections with the structure of reality. Value
language can be reduced to or translated into non-value language, i.e., to factual
language in terms of the descriptive-explanatory language of natural science.
This is usually done in terms of the language of psychology such that value
judgements become empirically verifiable by observation of behavior. Thus,
64 DONNIE J. SELF

utilitarianism, a paradigm of this position, reduces value judgements to judge-

ments of utility which are ultimately explicated in terms of the production of
pleasure and avoidance of pain and therefore is subjectivistic with respect to
value experience, but yet objectivistic with respect to value language.
Lastly, pure objectivism is the exact opposite of pure subjectivism. It is
objectivistic with respect to both value experience and value language. Objectiv-
ism in value theory is the belief that values are expressions of moral requirements
and normative imperatives emanating from an external value structure or moral
order in the world. To be objective simply means being independent of experi-
ence. Objective reality is held to exist independently of one's experience of it or
one's thoughts and feeling about it. Similarly, objectivism in value theory holds
that value requirements and normative imperatives exist independently of one's
experience of them or one's thoughts and feelings about them. Emotive repulsion
to cruelty such as in child abuse would be an example of an objective normative
imperative which exists independently of how one feels about it. Indeed those
persons who are not repulsed by such cruelty are considered sick and in need
of help. The formal ethics of Immanuel Kant and the Judeo-Christian ethics
of the Old and New Testaments are the best known paradigms of objectivism.
Objectivism holds that value judgements are objective in that they are cognitively
significant and make a knowledge claim which can be confirmed to be true or
false. They embody a significant semantic claim. The content of value judgements
is not dependent upon the peculiarities of the agent but is determinable by
any rational observer appraised of the relevant facts. Pure objectivism maintains
that value language is not reducible to non-value language since value experience
discerns a dimension of reality not discernible through any other mode of
experience. Value judgements are not merely expressions of emotions or attempts
to evoke similar attitudes in others, but rather are of and about an external
value structure, for value experience itself is held to be epistemic or knowledge-
yielding and a discernment of the objective external value structure or moral
order of the world. Values exist independently of a discerning mind, and there
are norms or value requirements regardless of whether or not anyone is aware of
them. Like necessary connections, they are not dependent upon knowledge of
them. Value language is of and about features of reality which are semantically
located in and come to be understood through value experience. Value language
is expressive of this value experience, i.e., it translates into language what is
semantically present in value experience. It relates a dimension of experience
which is not expressible through any other language. Value language is not
reducible or translatable into any other language such as factual language.
No other kind of language can express the content expressed in an ordinary
value judgement. The dimension of reality discerned through value experience
cannot be discerned through any other mode of experience.
 ETHICAL DECISION-MAKING OF PHYSICIANS 65

5. DISCUSSION

With the above understanding of the subjective-objective distinction in value

theory, the data collected from the questionnaires can be interpreted more
clearly. Analysis of the data requires that hypothesis number one be accepted
and shows that it is true that most physicians tend to be objectivist in value
theory, i.e., believe that value judgements are knowledge claims capable of
being true or false and are expressions of moral requirements and normative
imperatives emanating from an external value structure or moral order in the
world. This conclusion is particularly interesting in view of the fact that our
culture has become increasingly subjectivistic with respect to values since
the turn of the century with a subsequent tremendous rise in popularity of
existentialist thought. The conclusion is supported by the following three pieces
of evidence. The responses to the three questions relating to the objectivist
position (numbers 2, 3, and 4) endorsed strongly an objectivist point of view
with regard to ethical decision-making. The responses to the three questions
relating to the middle position, such as utilitarianism, (numbers 1, 6, and 8)
which is partially subjective and partially objective indicated that physicians
are basically not utilitarian in ethical decision-making. The responses to the
three questions relating to the subjectivist position (numbers 5, 7, and 9)
endorsed only weakly a subjectivist point of view with regard to ethical decision-
making. Each of these three pieces of evidence will be elaborated briefly.
First, in questions 2, 3, and 4 an affirmative response requires an objectivist's
stance philosophically. For example, an affirmative response to question number
2 regarding the possibility of right and wrong answers to ethical questions
requires that value judgements in general and ethical judgements in particular
be cognitive or l~mowledge-yielding in character with an epistemic content
- a requirement which is inconsistent with the subjectivist position. Yet, a
majority of the respondents (52.17%) answered question number 2 affirmatively.
Similarly, an affirmative answer to question number 3 (85.71%) regarding the
relativity of values requires that values be relative to the objective, external
facts of the situation and not simply relative to the subjective opinion of the
person making the value judgement. This point which is frequently misunder-
stood has been elaborated in more detail elsewhere.3 But the strongest evidence
corroborating the first hypothesis is found in the response to question number
4 regarding the existence of ethical obligations independently of knowledge of
them. Question number 4 had the most uniformly affirmative response (94.94%)
of any of the questions. However, the existence of ethical obligations indepen-
dent of knowledge of them entails that values exist independently of a discerning
mind and that there are normative imperatives and value requirements in reality
which reflect the existence of a normative structure or moral order in the world.
66 DONNIE J. SELF

The existence of such a moral order or of ethical obligations independently

of knowledge of them as endorsed by almost all the physicians is philosophically
inconsistent with the subjectivist stance which claims that value judgements
are purely personal private expressions of one's own opinion and inner-subjective
feelings.
Secondly, an analysis of the three questions renting to the middle position
(numbers 1, 6, and 8) in the subjective-objective issue supports the position
that the first hypothesis is a true statement. For example, the large negative
response to question number 6 (66.67%) regarding the rightness and wrongness
of an act being determined by its consequences, which is absolutely essential
to utilitarianism, indicates that most physicians are basically not utilitarian
in their philosophical stance to ethical decision-making. However, the over-
whelming positive response to question number 1 (87.20%) regarding the greatest
good for the greatest number shows that when consequences are considered
physicians are pluralistic utilitarians with multiple foci of concern. Moreover,
the negative response to question number 8 regarding always seeking the best
welfare of the patient corroborates this by indicating that the majority of phys-
icians are not monistic utilitarians with a singular concern. That is, with regard
to the perceived morality or rightness of their acts, physicians take many factors
into consideration and not just the usefulness of their act in terms of one pre-
eminent factor - not even the welfare of the patient solely.
Thirdly, the three questions relating to the subjectivist position (numbers
5, 7, and 9) while supporting certain subjectivistic tendencies, did so to a weak
degree. The strongest support for subjectivism was found in the response to
question number 7 regarding values being relative to the person making the
judgement where an affirmative response (66.53%) would be philosophically
consistent with the subjectivist stance. The second strongest support for subjec-
tivism was found in the response to question number 9 regarding the possibility
of value judgements being either true or false where a negative response (62.92%)
would be required for support. However, these two responses fell 20 to 30 per-
centage points below the two strongest supporting responses (numbers 3 and 4)
to the objectivist stance. Finally, in question number 5 regarding the rightness or
wrongness of acts regardless of the situation and circumstances where a negative
response would have supported subjectivism the affirmative responses (48.24%)
and the negative responses (51.76%) were almost evenly divided.
Comparison of the means of the sets of questions (Table III) supports the
interpretation of the data given above. The objectivist set of questions, numbers
2 - 4 , which required an affirmative response to each for support of the objectivist
position yielded a mean supportive response of 77.60%. The partial objectivist
and partial subjectivist set of questions, numbers 1, 6, and 8, which supported
a greatest good for the greatest number position when questions 1 and 6 were
 ETHICAL DECISION-MAKING OF PHYSICIANS 67

answered affirmatively and question number 8 answered negatively, yielded a

mean supportive response of 59.22%. The subjectivist set of questions, numbers
5, 7, and 9, which required an affirmative response to question number 7 and a
negative response to questions 5 and 9 to be supportive, yielded a mean suppor-
tive response of 60.40%. Thus it is seen that on the average the respondents
supported the objectivist position by 17.20% points over the subjectivist posi-
tion, and by 18.38% points over the partial objectivist and partial subjectivist
position.
Similarly, analysis of the data requires that hypothesis number 2 be accepted
and shows that it is true that most physicians are inconsistent in the philosophi-
cal foundations of their medical ethical decision-making regardless of whichever
position they tend to hold on the subjective-objective issue in value theory.
This is to say that physicians simultaneously hold some subjective beliefs and
some objective beliefs about values which are philosophically incompatible with
each other. This conclusion was demonstrated in two ways, namely, by pairing
related questions and noting the responses of the physicians overall and by
analyzing the individual responses to the questionnaires.
Table IV shows the question pairings, the responses required for consistency,
and the actual responses received from the group as a whole. In three of the five
question pairs the responses received differed from the theoretically consistent
pattern. For example, with questions 2 and 9, which would require two affirma-
tive responses or two negative responses for consistency, the actual response
received was a majority of affirmative responses to question 2 and a majority of
negative responses to question 9. Similarly, other pairs exhibited inconsistencies.
From this one can conclude that when the group is viewed as a whole, physicians
are inconsistent in the philosophical foundations of their medical ethical deci-
sion-making. This is not to say that they are any more or less inconsistent
than any other group or profession. But even if inconsistency in ethical decision-
making is universal it is still undesirable.
In addition to physicians being inconsistent with each other in the philosophi-
cal foundations of their medical ethical decision-making when the group is
viewed as a whole, it was also found that there were individual inconsistencies
in most physicians with regard to the philosophical foundations of their medical
ethical decision-making. For example, 236 (90.77%) of the respondents gave
at least one inconsistent response to the question pairs. Table V gives a surmnary
of the number of inconsistent responses to each of the question pairs.
Table VI shows a comparison of the consistency of response to the question
pairs on an individual basis. It reveals that the consistency of the individual
physician is much better than it was as a group for as a group the majority
of actual responses were inconsistent in 3 of the 5 question pairs. However, it
still leaves much to be desired for the data reveal that from the two best showings
68 DONNIE J. SELF

of consistency ~airs 2 & 9 and 1 & 8), the responses were consistent only about
two-thirds of the time and that in the other three question pairs the responses
were on the average, consistent less than half of the time. This indicates that
in t h e process of determining values physicians frequently hold beliefs which
are incompatible with their other beliefs about values. This strongly supports
acceptance of the second hypothesis.

6. CONCLUSION

The acceptance of hypothesis 2 is not to say that physicians are inconsistent in

their actual medical ethical decisions (although one would suspect this if their
philosophical foundations are inconsistent) but only that the responses they
give to questions about how medical ethical questions are to be determined,
require inconsistent philosophical stances in value theory. Thus one should
be careful not to confuse medical ethical decisions with questions about medical
ethical decision-making, i.e., with the methodology for determining the response
to a medical ethical question. Basically the difference is in asking what to do
as opposed to asking how to determine what to do. Medical ethical questions
are 'what' questions. Methodological questions about medical ethical decision-
making are 'how' questions. For example, the question of whether or not to
turn off the respirator on a particular terminal patient is a medical ethical
question, but determining the grounds for turning off respirators, whether it be
for the welfare of the patient or the welfare of all concerned, is a philosophical
question about the methodology for determining medical ethical decisions. It
might be noted here that none of the questions on the questionnaire are medical
ethical questions, rather they are questions about the various philosophical
stances which determine the methodology for medical ethical decision-making.
Perhaps medical ethical questions would not seem so difficult if the philosophical
questions could be agreed upon.
Lastly, the large affirmative response to question 10 (83.07%) concerning
the need for more emphasis to be placed upon medical ethics in medical educa-
tion indicates that the medical profession perceives the need for more instruction
in medical ethics. Since conceptual clarification and consistency in logical
reasoning are major aims of philosophy, perhaps an increase in exposure to
medical ethics would give physicians a better understanding of the philosophical
foundations of medical ethical decision-making and help eliminate some of the
inconsistency in their philosophical stances concerning medical ethical issues.

DONNIE J, SELF
Eastern VirginiaMedical School,
Norfolk, Virginia 23501 U.S.A.
 E T H I C A L D E C I S I O N - M A K I N G OF P H Y S I C I A N S 69

NOTES

1 For the context of this remark see [1].

2 For an extensive elaboration of the positions in the subjective-objective distinction and
the arguments for and against each position see [2, 3, 4, 5].
3 The point of values being relative to the person making the judgement versus values
being relative to the facts of the circumstances is often not well understood. This issue
is addressed in [3].

REFERENCES

[ 1 ] Adams, E. M., 'The grounds of ethics', Department of Philosophy, University of North

Carolina, Chapel Hilt, (n.d.), p. 6.
[2] Serf, D. J., 'Inconsistent presuppositions of Dewey's pragmatism', The Journal of
Educational Thought 10, (1976) 103-104.
[3] Self, D. J., 'Methodological considerations for medical ethics', Science, Medicine and
ivlan 1, (1974) 201.
[4] Self, D. J., 'Philosophical foundations of various approaches to medical ethical decision-
making', The Journal of Medicine and Philosophy 4, (1979) 20-31.
{5] Self, D. J., Value Language and Objectivity: An Analysis in Philosophical Ethics,
Doctoral Dissertation, University of North Carolina, Chapel Hill, 1973.