Assessing a group of physicians' ethical sensitivity in Turkey.

BACKGROUND: The objective was to measure the sensitivity of a group of physicians regarding the ethics-related situations, which they faced during patient care and treatment.
METHODS: All of 306 physicians who joined the Turkish Army for compulsory military service in December 2008 were included in the study. A "Moral Sensitivity Questionnaire", formed by Kim Lutzen, was applied to all of them.
RESULTS: From total, 95% of physicians performed their job willingly, 88% of physicians attended ethic lessons (n=265), 72.4% (n=218) followed ethic publications, 67.4% (n=203) stated that there was an ethic committee at their institutions, and 5% worked as a member of the ethic committee. There were statistically significant differences between autonomy, benevolence meaning, conflict, and total scores according to workplace of physicians, employment period, and being specialists. Points of autonomy were found lower in physicians working at private hospital and health center than those at public hospital.
CONCLUSION: Ethical sensitivity of physicians changed due to work place. We conclude that organizational arrangements are of beneficial effects to increase ethical sensitivity.

Introduction

The ultimate goal of medicine is making people healthy and saving lives and throughout the history physicians adhere to certain rules or traditions to provide health care. Achieving this goal becomes a valid reason for the choice of action that has to be taken. Physicians have to make decisions and sometimes choose one ultimately from several difficult alternatives of actions (1).

As a result, in each situation ethical dimensions of the situation should be taken into account. Both ethical sensitivity and ethical knowledge are sine qua non for determining ethical problems from others (2, 3).

There are many ethical dimensions such as moral burden, peace and responsibility. Therefore ethical sensitivity requires a consciousness on these ethical dimensions (4). Currently, both the philosophical and conceptual perspective and the social and political perspective of the ethical sensitivity are taken into account by many (5). However it has become a problematic issue since the ethical problems are perceived differently (6).

The ethical problems are mainly experienced amongst the patients, community, healthcare professionals and health managers due to patient and health professional relations, patient rights and responsibilities, confidentiality, resource allocation, health plan regulations (7). The managers of the healthcare institutions have a definitive role with respect to the ethical behavior of the staff (5). The conflict between the physician and the health board management on marketing policies in healthcare institutions has impacted on the development of the health ethics committees (8).

It is very difficult to make a decision on vital issues in the healthcare institutions (6). Value perspective, working environment, information and experience, roles and relations with the patients are all important factors that have an influence on ethical actions among healthcare staff (7). The ethical conflicts are mainly experienced amongst the patients, community, healthcare professionals and health managers due to patient and health professional relations, patient rights and responsibilities, confidentiality, resource allocation, health plan regulations (9). Among the issues of the ethics committees are the uses of individual autonomy, telling the truth to the patient, importance of confidentiality, helping people while considering the balance of benefits and harms. Not risking the patient’s condition in risky situations, equal distribution of resources and costs and the ethic codes of the professional associations provide guidance in those matters (10).

When the physicians come across ethical problems, they use rational and irrational approaches. Rational approaches; are deontology which enables decision making, consequentiality which shows the benefits of the methods used, ethical principles which are used for making moral decisions, and the meritorious conduct consistent with the character of the decision maker. Irrational approaches are; submission consistent with the moral structure of the healthcare institution, following the example of another colleague, implementing what one thinks is right, trusting intuitions, continuing habits for similar conditions (11).

The physicians are sometimes in a position where they have to make vital decisions regarding their patients considering not only the scientific aspect of medicine but also the value analysis and the legal understanding (12).

The recent studies on work ethics show that ethical sensitivity, ethical justice and behavioral activities are face to face with ethical conflict (13).

Modern health care abounds with potential ethically conflicting situations for physicians. Physicians claim to experience distress due to such situations. The extent, however, to which physicians actually experience having to make ethically problematic choices and treatment decisions in their clinical work, is largely unknown. Experiencing ethically problematic situations might indicate ethical sensitivity, the capability for ethical reasoning, and explicitly held ethical values (14).

The aim of this study was to measure the sensitivity of a group of physicians regarding the ethics-related situations that they face during patient care and treatment.

Materials and Methods

All of 306 physicians, who applied for compulsory military service in 2008 December, were asked to complete the “Moral Sensitivity Questionnaire”, which was formed by Kim Lutzen and validated for Turkey by Tosun (2005) (15). In Tosuns’s study, Chronbach alpha level found as 0.84. They reported that overall scores and sub scales test-re test correlation were between 0.81–0.99. In our study, Chronbach alpha level between 0.71–0.79 at total and for subscales.

Moral Sensitivity Questionnaire Fivefold Likert type scale was used in the questionnaire. The moral sensitivity questionnaire consists of 30 items and 6 subtypes. The total score may vary between 30 and 150. The questionnaire consists of 7 items for autonomy (score: 7–35), 4 items for benevolence meaning (score: 4–20), 5 items for structuring moral meaning (score: 5–25), 3 items for conflict (score: 3–15), 4 items for following the rules (score: 4–20), 4 items for relational orientation (score: 4–20), and 3 items as others (score: 3–15). Those are; Autonomy is reflected in views that the principle of patient autonomy, meaning self-choice, must be respected (category: autonomy). Expressing benevolence refers to actions that are motivated by doing that which his believed to be ‘good’ or in the best interest of the patient (category: benevolence). Structuring moral meaning refers to making sense of a patient’s limited autonomy by finding that actions are meaningful, that is, they neither harm nor threaten the patient’s integrity (category: meaning) Experiencing moral conflict (category: conflict). Conflict means the conflicts experienced in terms of ethical sensitivity. Following the ‘rules’ refers to actions that are instructed by routines and ward policies (category: rules). Relational orientation is reflected in the health care professional’s concern for how actions will affect the relationship with the patient (category: relation) (16). The questions have positive expressions in questionnaire and the answer of “certainly agree” reflects most ethical approach. Dimensions vary between 1 “certainly agree” and 5 “certainly disagree”. Therefore, lower score is better from viewpoint of ethical sensitivity.

SPSS for Windows V. 15.0 was used for statistical analysis. The descriptive statistics were presented as frequency and percent for categorical data, and mean standard deviation and median (min-max) for continuous variables. Mann Whitney U and Kruskal Wallis tests were used for group comparisons. Bonferroni corrected Mann Whitney U test was used as post-hoc analysis. A P value of <0.05 was accepted as statistically significant.

Results

From all participants, 301 (98.3%) responded successfully the questionnaires. The age of these 301 physicians were in the range of 26 to 29 yr old (median: 32 yr). Of them, 42.5% (n= 128) were single, 57.5% (n=173) were married. While 42.2% (n=127) were general practitioner, the rest of 57.8% (n=174) were specialist. Their employment periods were in range of 1 to 12 yr but 61.5% of them worked less than 5 yr (n= 185). Regarding the institutions at which they worked before military service, participants distributed as 58.1% (n= 175) at public hospitals, 4% (n= 12) at university hospitals, 8.6% (n= 26) at private hospitals, 21.3% (n= 64) at health centers, and 8% (n= 24) at other institutions. As shown in Table 1, 95% of physicians performed their job willingly, 88% of physicians attended ethic lessons (n=265), 72.4% (n= 218) followed ethic publications, 67.4% (n= 203) cited that there was an ethic committee at their institutions, 5% worked as a member of ethic committee.

Table 1:

Demographic characteristics of the corresponders (n=301)

Characteristics		n	%
Workplace	Public Hospital	175	58.1
	University	12	4.0
	Private	26	8.6
	Health center	64	21.3
	Others	24	8.0
Marital status	Single	128	42.5
	Married	173	57.5
Employment period	1–5 years	185	61.5
	6–12 years	116	38.5
Status	Practitioner	127	42.2
	Specialist	174	57.8
Profession be loved	Yes	286	95.0
	No	15	5.0
Take ethic course	Yes	265	88.0
	No	36	12.0
Pay attention to publications	Yes	218	72.4
	No	83	27.6
Ethic committee	Yes	98	32.6
	No	203	67.4
Work on ethic committee	Yes	15	5.0
	No	286	95.0
Encounter problems	Yes	175	58.1
	No	126	41.9
Way to solution of problems	Encountered	106	35.2
	To make self	76	25.2
	Get help	28	9.3
	Could not figure out	91	30.2

According to the physicians’ institution, scores of ethical sensitivity measure was shown in Table 2. There were several statistically significant differences in ethical sensitivity scores (P< 0.05). In pairs comparisons, the physicians working at private hospitals and health centers had higher autonomy scores than those at public hospitals, which was found to be statistically significant (P< 0.05). In terms of total scores, groups working at private hospitals and health centers had significantly lower scores than group working at public hospitals (P< 0.05).

Table 2:

Comparison of ethical sensitivity scores of the corresponders according to the institutions

	Public Hospitals	University	Private Hospitals	Health Center	Others	Total	P*
	Mean+SD Median (Min-Max)	Mean+SD Median (Min-Max)	Mean+SD Median (Min-Max)	Mean+SD Median (Min-Max)	Mean+SD Median (Min-Max)	Mean+SD Median (Min-Max)
Autonomy	17.06+3.21	16.42+ 7.00	15.23+3.04	15.44+2.84	16.29+3.39	16.47+3.42	0.001
	17 (8–24)	15 (7–29)	15 (10–22)	15 (9–24)	16 (7–22)	16 (7–29)
Benevolence meaning	9.57+2.53	8.08+2.94	8.38+1.77	8.72+2.82	10.00+2.34	9.26+2.58	0.008
	10 (4–18)	8 (4–15)	8 (4–12)	9 (4–15)	9.5 (7–14)	9 (4–18)
Structuring moral meaning	9.34+2.13	8.67+1.67	9.15+2.15	8.94+2.02	9.21+2.11	9.20+2.09	0.672
	9 (5–16)	9 (5–11)	9 (6–15)	9 (5–13)	9 (5–13)	9 (5–16)
Conflict	10.05+1.90	9.58+3.20	9.31+1.29	9.53+2.01	10.38+1.44	9.88+1.93	0.01
	10 (3–14)	11 (3–12)	9 (7–11)	9.5 (4–15)	10.5 (6–13)	10 (3–15)
Following the ‘rules’	9.78+2.36	8.17+2.12	9.15+2.15	9.38+1.77	9.38+1.93	9.54+2.21	0.133
	10 (4–18)	8.5 (4–10)	9.5 (6–15)	9 (6–13)	9 (5–13)	10 (4–18)
Relational orientation	7.11+2.59	6.17 +2.29	7.00+1.94	6.53+1.85	6.88+1.65	6.92+2.32	0.31
	7 (4–23)	6.5 (4–11)	7 (4–13)	7 (4–12)	7 (4–9)	7 (4–23)
Total	69.01+9.36	61.50+9.50	63.42+8.20	64.77+8.34	68.96+	67.33+9.18	<0.001
	69 (42–96)	65 (45–72)	62 (51–87)	66 45–84)	68 (57–87)	68 (42–96)

Kruskal Wallis test

The ethical sensitivity of practitioners (n= 127) was compared with those of specialists (n= 174) and the results were shown in Table 3. While autonomy, following the rules, and total scores were significantly higher in practitioners, conflict scores was significantly higher among specialists (P< 0.05).

Table 3:

Comparison of ethical sensitivity scores of the corresponders between practitioners and specialists

	Practitioner Mean+SD Median (Min-Max)	Specialist Mean+SD Median (Min-Max)	Total Mean+SD Median (Min-Max)	P*
Autonomy	15.71+3.08	17.02+3.55	16.47+3.41	0.001
	16 (7–24)	17 (7–29)	16 (7–29)
Benevolence meaning	8.93+2.44	9.49+2.65	9.25+2.57	0.051
	9 (4–15)	9.5 (4–18)	9 (4–18)
Structuring moral meaning	9.06+2.03	9.29+2.12	9.20+2.08	0.31
	9 (5–15)	9 (5–16)	9 (5–16)
Conflict	9.73+1.68	9.99+2.08	9.88+1.92	0.028
	10 (4–15)	10 (3–14)	10 (3–15)
Following the ‘rules’	9.28+1.74	9.73+2.47	9.54+2.20	0.047
	9 (6–15)	10 (4–18)	10 (4–18)
Relational orientation	6.73+1.75	7.06+2.66	6.92+2.32	0.56
	7 (4–13)	7 (4–23)	7 (4–23)
Others	7.37+1.71	7.57+2.04	7.49+1.91	0.171
	7 (3–12)	8 (3–12)	7.5 (3–12)
Total	65.49+7.89	68.65+9.80	67.33+9.17	<0.001
	67 (45–87)	70 (42–96)	68 (42–96)

Mann-Whitney U test result

Employment period was found to be 1 to 12 yr. Physicians were divided into two groups according to employment period, which consisted of less than 5 yr employment period (n= 185) and more than 5 yr employment period (n= 116), as shown in Table 4.

Table 4:

Comparison of ethical sensitivity scores of the corresponders according to employment period

	Period group	Mean+SD Median (Min-Max)	P*
Autonomy	1–5 years	16.13±3.03	0.028
		16 (8–24)
	6–12 years	17.02±3.90
		17 (7–29)
Benevolence meaning	1–5 years	9.02±2.46	0.039
		9 (4–15)
	6–12 years	9.65±2.71
		10 (4–18)
Structuring moral meaning	1–5 years	9.10±2.07	0.315
		9 (5–15)
	6–12 years	9.35±2.10
		9 (5–16)
Conflict	1–5 years	9.77±1.84	0.187
		10 (3–15)
	6–12 years	10.07±2.04
		10 (3–14)
Following the ‘rules’	1–5 years	9.23±1.87	0.004
		9 (4–15)
	6–12 years	10.04±2.58
		10 (4–18)
Relational orientation	1–5 years	6.98±2.49	0.571
		7 (4–23)
	6–12 years	6.83±2.02
		7 (4–12)
Others	1–5 years	7.31±1.73	0.049
		7 (3–12)
	6–12 years	7.78±2.14
		8 (3–12)
Total	1–5 years	66.18±8.43	0.006
		67 (42–87)
	6–12 years	69.17±10.01
		70 (45–96)

Mann-Whitney U test result.

The autonomy, benevolence meaning, following the rules, ethical sensitivity, and others were found statistically significant in physicians working less than 5 yr (P< 0.05).

From all 106 (35.2%) physicians stated that they never faced with ethical problems. From those who faced with ethical problems, 76 physicians solved these problems by themselves, 28 physicians asked for help from their colleagues, and 98 physicians did not find any solutions for these problems (Table 5). Autonomy, others, and total scores were better in the physicians who asked for help from their colleagues (P< 0.05). There was no significant difference and correlation between age and ethical score in all measure.

Table 5:

Comparison of ethical sensitivity scores of the corresponders according to problem solving algorithms.*

Solution	Not encountered		To make self		Get help		Could not figure out		Total
	n	Mean+SD Median (Min-Max)	n	Mean+SD Median (Min-Max)	n	Mean+SD Median (Min-Max)	n	Mean+SD Median (Min-Max)	n	Mean+SD Median (Min-Max)	P*
Autonomy	106	16.85±3.87	76	16.36±1.85	28	15.29±2.77	91	16.49±3.25	301	16.47±3.42	0.046
		17 (7–29)		16 (8–24)		15 (12–22)		16 (9–24)		16 (7–29)
Benevolence meaning	106	9.24±2.79	76	9.78±2.07	28	9.14±2.85	91	8.89±2.22	301	9.26±2.58	0.167
		9 (4–18)		10 (4–16)		9 (4–15)		9 (4–14)		9 (4–18)
Structuring moral meaning	104	9.31±2.17	76	9.03±2.15	28	9.07±1.74	91	9.26±2.04	299	9.20±2.09	0.883
		9 (5–15)		9 (5–14)		9 (5–13)		9 (5–16)		9 (5–16)
Conflict	106	10.03±1.93	76	9.93±1.90	28	9.36±1.93	91	9.84±1.94	301	9.88±1.93	0.444
		10 (3–14)		10 (4–15)		10 (5–12)		10 (3–14)		10 (3–15)
Following the ‘ r ules’	106	9.57±2.39	76	9.80±2.17	28	9.21±2.33	91	9.41±1.98	301	9.54±2.21	0.438
		10 (4–15)		10 (4–18)		9 (5–14)		9 (4–16)		10 (4–18)
Relational orientation	106	7.21±2.92	76	6.92±2.53	28	6.50±1.64	91	6.73±1.86	301	6.92±2.32	0.533
		7 (4–23)		7 (4–12)		6 (4–13)		7 (4–12)		7 (4–23)
Others	105	7.60±2.07	76	7.82±3.09	28	6.86±1.63	91	7.30±1.82	300	7.49±1.91	0.024
		8 (3–12)		8 (3–12)		6.5 (3–12)		7 (3–12)		7.5 (3–12)
Total	103	68.50±10.17	76	67.97±8.95	28	64.07±6.25	91	66.47±8.73	298	67.33±9.18	0.036
		69 (43–88)		69 (42–96)		62(57–76)		68 (45–91)		68 (42–96)

Kruskal Wallis test result

Discussion

It is a limitation that the adapted form (by Tosun) of Kim Lutzen’s “Moral Sensitivity Questionnaire” does not have cut-off points. Lower score reflects higher ethical sensitivity.

Differences in physicians’ total ethical sensitivity scores according to their institutions were found to be statistically significant. Mean scores in physicians working at private hospitals and health centers were significantly lower than those in physicians working at public hospitals. In our opinions, this condition might be explained by institutional climate. Institutional climate is a character of institution and emerged from personnel and shared general perceptions are known to effect personnel behaviors and tendencies (17).

Several previous studies has emphasized that institutional climate have had different dimensions. According to Lawler et al., institutional climate has emerged from personnel perception of institution, relationships, feelings, and other daily experiences as results of these (18). In Moran’s study, basic parameters, which determine institutional climate, were determined as autonomy, confidence, taking support, recognition, changing, and respecting the honesty. Norms formed by mutual interaction between workers of institution serving to interpret situations effect to shape workers’ actions and behaviors (19). It is impossible to think that institutional climate that shapes actions and affects behaviors, is not effective in ethical sensitivity. Therefore, we can claim that physicians’ ethical sensitivity is unavoidably being affected by climate of institution.

We thought the fact that physician working at health centers having lower ethical sensitivity scores might be explained by working away from close control, working more independently. Furthermore, physicians’ stress factors such as examination of more patients, limited time for decision-making, safety problems related to threats of physical violence and organizational climate might be thought as factors putting ethical sensitivity in a lower priority.

It was found that there were no statistically significant differences about autonomy in physicians and nurses working at public hospitals, private hospitals, and health centers (20). Likewise, Ersoy et al. did not find any relationship between institutions and ethical sensitivity (21). Conflict among the health service employees was determined to be lower in public hospitals than in university hospitals (15).

In comparison of practitioners to specialists, dimension scores of autonomy and following the rules, and total score were better in practitioners, while dimension scores of conflict were better in specialists.

Regarding employment period, autonomy, benevolence meaning, following the rules, and others were found to be significant differences in physicians working 5 yr or less. But Structuring moral meaning and conflict were found not to be statistically significant difference. As that the dimensions are high in newly graduated physicians who are more sensitive to ethical sensitivity may be one of the reason, increasing of working time may make physicians become estranged to their job, so reduction of the dimensions may be related to this. Previous studies regarding relationship between working hours and ethical sensitivity were seen to have found different results. For example, the mean of ethical sensitivity and working hours were getting higher in years (15). Ersoy et al. found that there were no significant difference between ethical sensitivity and working hours (21).

When asking physicians faced with ethical problems and how to cope with these problems; 106 of them said not to face with ethical problems, 76 physicians solved problems by themselves, 28 physicians said to get help from their colleagues, and also 98 physicians said not to find any solution to solve problems. Physician who said to get help from colleagues were found to be in good position with regard to autonomy, others and total scores, and this result was found to be emphasized the importance of occupational cooperation. When the opinions of physicians on ethical dimensions are determined according to whether they have faced ethical conflicts, a statistical significant difference has been found “following the rules” dimension (22).

When comparing the correlation between ages and ethical scores, there were found no significant and strong enough correlation in any measure scores. This situation might be explained that there were no big differences between age groups (range between, 26–39 yr old); whereas similar studies found that, there was a significant difference between parameters, especially orientation parallel to older ages. Previous studies found that there was a difference between 20–30 yr old and 41–50 yr old groups and orientation was reduced (15, 21).

The physicians have the primary legal responsibility in patient care and treatment. Lützén et al applied the moral sensitivity questionnaire to 113 general care physicians, 665 psychiatrists, 150 general care nurses and 145 psychiatry nurses, and as a result they found differences between the groups in terms of autonomy, benevolence, holistic approach, conflict but they found no difference in the practice and orientation dimensions (16).

Previous studies have shown that ethical sensitivity is an important component of the decision making process (16). Weaver et al. studied 200 ethics-related articles and books on nursing, medicine, psychology, dentistry, clinic impact, religion, education, law, accounting, journalism, politics, social sciences and women studies from 1970 to 2006. In this study, it was found the attitudes regarding ethical sensitivity included moral perception, effectiveness and loyalty (23).

Bégat et al. studied the relationship between the work environment and the moral sensitivity from a socio-cultural perspective in a study including 138 Japan and 71 Norwegian nurses. Japan nurses works with a more patient-centred perspective than the Norwegian nurses do. Japan nurses consider as important the relations between the head nurse and the colleagues, work stress and the anxiety respectively in patient care rather than moral conflict. Norwegian nurses emphasized that work stress and anxiety were not very important in moral conflict. However, significant correlations were found between the physical and mental symptoms and moral conflict amongst the Norwegian nurses (24).

It would be of interest to carry out a comparative study of physicians from different countries in order to investigate the influence of cultural and social factors. It would also be of interest to do a qualitative study, such as in-depth interviews, focused on how individual physicians reason when confronted with moral dilemmas. In interviews, other factors may be identified, which could further develop the concept of moral sensitivity and, in turn, the psychometric dimension of the Moral Sensitivity Questionnaire.

Ethical Considerations

Ethical issues including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc. have been completely observed by the authors.