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Ethical decision-making about older adults and moral intensity: an international study of physicians
  1. D C Malloy1,2,
  2. J Williams2,3,
  3. T Hadjistavropoulos2,3,
  4. B Krishnan1,2,
  5. M Jeyaraj4,
  6. E F McCarthy5,
  7. M Murakami6,
  8. S Paholpak7,
  9. J Mafukidze1,
  10. B Hillis8
  1. 1
    Faculty of Kinesiology & Health Studies, University of Regina, Regina, Canada
  2. 2
    Centre on Aging and Health, University of Regina, Regina, Canada
  3. 3
    Department of Psychology, University of Regina, Regina, Canada
  4. 4
    Madras Medical College, Madras, India
  5. 5
    School of Nursing and Midwifery, Trinity College, Dublin, Ireland
  6. 6
    Department of Sociology, Meiji Gakuin University, Tokyo, Japan
  7. 7
    Department of Psychiatry, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
  8. 8
    Department of Religious Studies, Luther College, University of Regina, Regina, Canada
  1. Dr D C Malloy, Faculty of Kinesiology & Health Studies, University of Regina, Regina, SK, Canada, S4S 0A2; David.Malloy{at}


Through discourse with international groups of physicians, we conducted a cross-cultural analysis of the types of ethical dilemmas physicians face. Qualitative analysis was used to categorise the dilemmas into seven themes, which we compared among the physicians by country of practice. These themes were a-theoretically-driven and grounded heavily within the text. We then subjected the dilemmas to an analysis of moral intensity, which represents an important (albeit novel within healthcare research) theoretical perspective of ethical decision making. These constructs (ie, culture and moral intensity) represent salient determinants of ethical behaviour and our cross-cultural sample afforded us the opportunity to consider both the pragmatic aspects of culture, as they are perceived by physicians, as well as the theory-driven concept of moral intensity. By examining both culture and moral intensity, we hope to better elucidate the complexities of ethical decision-making determinants among physicians in their daily practice. Doing so may potentially have practical implications for ethics training of medical students and foreign physicians.

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  • Competing interests: None.

  • Ethics approval: Ethics clearance was obtained from the Reseach Ethics Board, University of Regina, Regina, Canada.

  • i The term moral intensity can be perceived as ethical intensity as the literature in this area does not distinguish between the two terms. The philosophical literature separates these terms. For example, Aristotle and Aquinas perceive morals as being universal concepts and ethics as being contextual.

  • ii It must be noted that while data from an Islamic country was sought after, political and travel complexities made it impossible in the post 9/11 environment.

  • iii Note that Japan is primarily influenced by Buddhist, Confucian, and Shinto faiths; whereas Thailand is predominantly Buddhist in orientation (see table 1).

  • iv It should be noted here and in table 2 that in Japan and Thailand the majority of participants were psychiatrists. This was the case due to the availability of peer nominated physicians who have clinical experience working with seniors with dementia and who were willing to take part in this study.

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