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McCombs School of Business

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Case Studies

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

A Million Little Pieces

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

Abramoff: Lobbying Congress

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

Apple Suppliers & Labor Practices

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

Approaching the Presidency: Roosevelt & Taft

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

Appropriating “Hope”

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

Arctic Offshore Drilling

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

Banning Burkas: Freedom or Discrimination?

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

Birthing Vaccine Skepticism

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

Blurred Lines of Copyright

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

Bullfighting: Art or Not?

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

Buying Green: Consumer Behavior

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

Cadavers in Car Safety Research

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

Cardinals’ Computer Hacking

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

Cheating: Atlanta’s School Scandal

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

Cheating: Sign-Stealing in MLB

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

Cheating: UNC’s Academic Fraud

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

Cheney v. U.S. District Court

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

Christina Fallin: “Appropriate Culturation?”

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

Climate Change & the Paris Deal

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

Cover-Up on Campus

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

Covering Female Athletes

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

Covering Yourself? Journalists and the Bowl Championship

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

Cyber Harassment

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

Defending Freedom of Tweets?

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

Dennis Kozlowski: Living Large

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

Digital Downloads

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

Dr. V’s Magical Putter

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

East Germany’s Doping Machine

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

Ebola & American Intervention

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

Edward Snowden: Traitor or Hero?

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

Ethical Pitfalls in Action

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

Ethical Use of Home DNA Testing

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

Flying the Confederate Flag

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

Freedom of Speech on Campus

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

Freedom vs. Duty in Clinical Social Work

What should social workers do when their personal values come in conflict with the clients they are meant to serve?

Full Disclosure: Manipulating Donors

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

Gaming the System: The VA Scandal

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

German Police Battalion 101

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

Head Injuries & American Football

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

Head Injuries & the NFL

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

Healthcare Obligations: Personal vs. Institutional

A medical doctor must make a difficult decision when informing patients of the effectiveness of flu shots while upholding institutional recommendations.

High Stakes Testing

In the wake of the No Child Left Behind Act, parents, teachers, and school administrators take different positions on how to assess student achievement.

In-FUR-mercials: Advertising & Adoption

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

Krogh & the Watergate Scandal

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

Limbaugh on Drug Addiction

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

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

Meet Me at Starbucks

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

Myanmar Amber

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

Negotiating Bankruptcy

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

Pao & Gender Bias

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

Pardoning Nixon

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

Patient Autonomy & Informed Consent

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

Prenatal Diagnosis & Parental Choice

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

Reporting on Robin Williams

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

Responding to Child Migration

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

Retracting Research: The Case of Chandok v. Klessig

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

Sacking Social Media in College Sports

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

Selling Enron

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

Snyder v. Phelps

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

Something Fishy at the Paralympics

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

Sports Blogs: The Wild West of Sports Journalism?

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

Stangl & the Holocaust

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

Teaching Blackface: A Lesson on Stereotypes

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

The Astros’ Sign-Stealing Scandal

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

The Central Park Five

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

The CIA Leak

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

The Collapse of Barings Bank

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

The Costco Model

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

The FBI & Apple Security vs. Privacy

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

The Miss Saigon Controversy

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

The Sandusky Scandal

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

The Varsity Blues Scandal

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

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

Welfare Reform

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

Wells Fargo and Moral Emotions

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

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Annual Review of Ethics Case Studies

What are research ethics cases.

For additional information, please visit Resources for Research Ethics Education

Research Ethics Cases are a tool for discussing scientific integrity. Cases are designed to confront the readers with a specific problem that does not lend itself to easy answers. By providing a focus for discussion, cases help staff involved in research to define or refine their own standards, to appreciate alternative approaches to identifying and resolving ethical problems, and to develop skills for dealing with hard problems on their own.

Research Ethics Cases for Use by the NIH Community

• Theme 23 – Authorship, Collaborations, and Mentoring (2023)
• Theme 22 – Use of Human Biospecimens and Informed Consent (2022)
• Theme 21 – Science Under Pressure (2021)
• Theme 20 – Data, Project and Lab Management, and Communication (2020)
• Theme 19 – Civility, Harassment and Inappropriate Conduct (2019)
• Theme 18 – Implicit and Explicit Biases in the Research Setting (2018)
• Theme 17 – Socially Responsible Science (2017)
• Theme 16 – Research Reproducibility (2016)
• Theme 15 – Authorship and Collaborative Science (2015)
• Theme 14 – Differentiating Between Honest Discourse and Research Misconduct and Introduction to Enhancing Reproducibility (2014)
• Theme 13 – Data Management, Whistleblowers, and Nepotism (2013)
• Theme 12 – Mentoring (2012)
• Theme 11 – Authorship (2011)
• Theme 10 – Science and Social Responsibility, continued (2010)
• Theme 9 – Science and Social Responsibility - Dual Use Research (2009)
• Theme 8 – Borrowing - Is It Plagiarism? (2008)
• Theme 7 – Data Management and Scientific Misconduct (2007)
• Theme 6 – Ethical Ambiguities (2006)
• Theme 5 – Data Management (2005)
• Theme 4 – Collaborative Science (2004)
• Theme 3 – Mentoring (2003)
• Theme 2 – Authorship (2002)
• Theme 1 – Scientific Misconduct (2001)

For Facilitators Leading Case Discussion

For the sake of time and clarity of purpose, it is essential that one individual have responsibility for leading the group discussion. As a minimum, this responsibility should include:

• Reading the case aloud.
• Defining, and re-defining as needed, the questions to be answered.
• Encouraging discussion that is “on topic”.
• Discouraging discussion that is “off topic”.
• Keeping the pace of discussion appropriate to the time available.
• Eliciting contributions from all members of the discussion group.
• Summarizing both majority and minority opinions at the end of the discussion.

How Should Cases be Analyzed?

Many of the skills necessary to analyze case studies can become tools for responding to real world problems. Cases, like the real world, contain uncertainties and ambiguities. Readers are encouraged to identify key issues, make assumptions as needed, and articulate options for resolution. In addition to the specific questions accompanying each case, readers should consider the following questions:

• Who are the affected parties (individuals, institutions, a field, society) in this situation?
• What interest(s) (material, financial, ethical, other) does each party have in the situation? Which interests are in conflict?
• Were the actions taken by each of the affected parties acceptable (ethical, legal, moral, or common sense)? If not, are there circumstances under which those actions would have been acceptable? Who should impose what sanction(s)?
• What other courses of action are open to each of the affected parties? What is the likely outcome of each course of action?
• For each party involved, what course of action would you take, and why?
• What actions could have been taken to avoid the conflict?

Is There a Right Answer?

Acceptable solutions.

Most problems will have several acceptable solutions or answers, but it will not always be the case that a perfect solution can be found. At times, even the best solution will still have some unsatisfactory consequences.

Unacceptable Solutions

While more than one acceptable solution may be possible, not all solutions are acceptable. For example, obvious violations of specific rules and regulations or of generally accepted standards of conduct would typically be unacceptable. However, it is also plausible that blind adherence to accepted rules or standards would sometimes be an unacceptable course of action.

Ethical Decision-Making

It should be noted that ethical decision-making is a process rather than a specific correct answer. In this sense, unethical behavior is defined by a failure to engage in the process of ethical decision-making. It is always unacceptable to have made no reasonable attempt to define a consistent and defensible basis for conduct.

This page was last updated on Friday, July 7, 2023

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• 30 Apr 2024

When Managers Set Unrealistic Expectations, Employees Cut Ethical Corners

Corporate misconduct has grown in the past 30 years, with losses often totaling billions of dollars. What businesses may not realize is that misconduct often results from managers who set unrealistic expectations, leading decent people to take unethical shortcuts, says Lynn S. Paine.

• 23 Apr 2024
• Cold Call Podcast

Amazon in Seattle: The Role of Business in Causing and Solving a Housing Crisis

In 2020, Amazon partnered with a nonprofit called Mary’s Place and used some of its own resources to build a shelter for women and families experiencing homelessness on its campus in Seattle. Yet critics argued that Amazon’s apparent charity was misplaced and that the company was actually making the problem worse. Paul Healy and Debora Spar explore the role business plays in addressing unhoused communities in the case “Hitting Home: Amazon and Mary’s Place.”

• 15 Apr 2024

Struggling With a Big Management Decision? Start by Asking What Really Matters

Leaders must face hard choices, from cutting a budget to adopting a strategy to grow. To make the right call, they should start by following their own “true moral compass,” says Joseph Badaracco.

• 26 Mar 2024

How Do Great Leaders Overcome Adversity?

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

• 02 Jan 2024

Should Businesses Take a Stand on Societal Issues?

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

• 12 Dec 2023

Can Sustainability Drive Innovation at Ferrari?

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

• 11 Dec 2023
• Research & Ideas

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

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

• 27 Nov 2023

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

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

• 21 Nov 2023

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

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

• 09 Nov 2023

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

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

• 07 Nov 2023

How Should Meta Be Governed for the Good of Society?

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

• 24 Oct 2023

From P.T. Barnum to Mary Kay: Lessons From 5 Leaders Who Changed the World

What do Steve Jobs and Sarah Breedlove have in common? Through a series of case studies, Robert Simons explores the unique qualities of visionary leaders and what today's managers can learn from their journeys.

• 03 Oct 2023
• Research Event

Build the Life You Want: Arthur Brooks and Oprah Winfrey Share Happiness Tips

"Happiness is not a destination. It's a direction." In this video, Arthur C. Brooks and Oprah Winfrey reflect on mistakes, emotions, and contentment, sharing lessons from their new book.

• 12 Sep 2023

Successful, But Still Feel Empty? A Happiness Scholar and Oprah Have Advice for You

So many executives spend decades reaching the pinnacles of their careers only to find themselves unfulfilled at the top. In the book Build the Life You Want, Arthur Brooks and Oprah Winfrey offer high achievers a guide to becoming better leaders—of their lives.

• 10 Jul 2023
• In Practice

The Harvard Business School Faculty Summer Reader 2023

Need a book recommendation for your summer vacation? HBS faculty members share their reading lists, which include titles that explore spirituality, design, suspense, and more.

• 01 Jun 2023

A Nike Executive Hid His Criminal Past to Turn His Life Around. What If He Didn't Have To?

Larry Miller committed murder as a teenager, but earned a college degree while serving time and set out to start a new life. Still, he had to conceal his record to get a job that would ultimately take him to the heights of sports marketing. A case study by Francesca Gino, Hise Gibson, and Frances Frei shows the barriers that formerly incarcerated Black men are up against and the potential talent they could bring to business.

• 04 Apr 2023

Two Centuries of Business Leaders Who Took a Stand on Social Issues

Executives going back to George Cadbury and J. N. Tata have been trying to improve life for their workers and communities, according to the book Deeply Responsible Business: A Global History of Values-Driven Leadership by Geoffrey Jones. He highlights three practices that deeply responsible companies share.

• 14 Mar 2023

Can AI and Machine Learning Help Park Rangers Prevent Poaching?

Globally there are too few park rangers to prevent the illegal trade of wildlife across borders, or poaching. In response, Spatial Monitoring and Reporting Tool (SMART) was created by a coalition of conservation organizations to take historical data and create geospatial mapping tools that enable more efficient deployment of rangers. SMART had demonstrated significant improvements in patrol coverage, with some observed reductions in poaching. Then a new predictive analytic tool, the Protection Assistant for Wildlife Security (PAWS), was created to use artificial intelligence (AI) and machine learning (ML) to try to predict where poachers would be likely to strike. Jonathan Palmer, Executive Director of Conservation Technology for the Wildlife Conservation Society, already had a good data analytics tool to help park rangers manage their patrols. Would adding an AI- and ML-based tool improve outcomes or introduce new problems? Harvard Business School senior lecturer Brian Trelstad discusses the importance of focusing on the use case when determining the value of adding a complex technology solution in his case, “SMART: AI and Machine Learning for Wildlife Conservation.”

• 14 Feb 2023

Does It Pay to Be a Whistleblower?

In 2013, soon after the US Securities and Exchange Commission (SEC) had started a massive whistleblowing program with the potential for large monetary rewards, two employees of a US bank’s asset management business debated whether to blow the whistle on their employer after completing an internal review that revealed undisclosed conflicts of interest. The bank’s asset management business disproportionately invested clients’ money in its own mutual funds over funds managed by other banks, letting it collect additional fees—and the bank had not disclosed this conflict of interest to clients. Both employees agreed that failing to disclose the conflict was a problem, but beyond that, they saw the situation very differently. One employee, Neel, perceived the internal review as a good-faith effort by senior management to identify and address the problem. The other, Akash, thought that the entire business model was problematic, even with a disclosure, and believed that the bank may have even broken the law. Should they escalate the issue internally or report their findings to the US Securities and Exchange Commission? Harvard Business School associate professor Jonas Heese discusses the potential risks and rewards of whistleblowing in his case, “Conflicts of Interest at Uptown Bank.”

• 17 Jan 2023

Good Companies Commit Crimes, But Great Leaders Can Prevent Them

It's time for leaders to go beyond "check the box" compliance programs. Through corporate cases involving Walmart, Wells Fargo, and others, Eugene Soltes explores the thorny legal issues executives today must navigate in his book Corporate Criminal Investigations and Prosecutions.

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• “Ad”mission of guilt
• “Do I stop him?”
• Newspaper joins war against drugs
• Have I got a deal for you!
• Identifying what’s right
• Is “Enough!” too much?
• Issues of bench and bar
• Knowing when to say “when!”
• Stop! This is a warning…
• Strange bedfellows
• Gambling with being first
• Making the right ethical choice can mean winning by losing
• Playing into a hoaxster’s hands
• “They said it first”
• Is it news, ad or informercial?
• Letter to the editor
• Games publishers play
• An offer you can refuse
• An oily gift horse
• Public service . . . or “news-mercials”
• As life passes by
• Bringing death close
• A careless step, a rash of calls
• Distortion of reality?
• Of life and death
• Naked came the rider
• “A photo that had to be used”
• A picture of controversy
• Freedom of political expression
• Brother, can you spare some time?
• Columnist’s crusade OK with Seattle
• Kiss and tell
• The making of a govenor
• Past but not over
• Of publishers and politics
• To tell the truth
• Truth & Consequences
• “Truth boxes”
• When journalists become flacks
• A book for all journalists who believe
• The Billboard Bandit
• Food for thought
• Grand jury probe
• Judgement on journalists
• Lessons from an ancient spirit
• Lying for the story . . .
• Newspaper nabs Atlanta’s Dahmer
• One way to a good end
• Over the fence
• “Psst! Pass it on!”
• Rules aren’t neat on Crack Street
• “Someone had to be her advocate”
• Trial by Fire
• Trial by proximity
• Using deceit to get the truth
• When advocacy is okay
• Witness to an execution
• Are we our brother’s keeper? . . . You bet we are!
• Betraying a trust
• Broken promise
• “But I thought you were . . . ”
• “Can I take it back?”
• Competitive disadvantage
• Getting it on tape
• The great quote question
• How to handle suicide threats
• Let’s make a deal!
• A phone-y issue?
• The source wanted out
• The story that died in a lie
• Thou shalt not break thy promise
• Thou shalt not concoct thy quote
• Thou shalt not trick thy source
• Too good to be true
• Vulnerable sources and journalistic responsibility
• The way things used to be . . .
• When a story just isn’t worth it
• When a story source threatens suicide
• When public should remain private
• The ethics of “outing”
• “For personal reasons”
• Intruding on grief
• Intruding on private pain
• Privacy case settled against TV station
• Seeing both sides
• Two views on “outing”
• Unwanted spotlight
• Whose right is it anyway?
• Other views on the Christine Busalacchi case
• The death of a soldier
• Firing at Round Rock
• A kinder, gentler news media
• Operation: Buy yourself a parade
• Rallying ’round the flag
• “Salute to military” ads canceled
• Tell the truth, stay alive
• The windbags of war
• Absent with no malice
• Anonymity for rape victims . . .
• An exception to the rule
• The boy with a broken heart
• Civilly suitable
• Creating a victim
• “Everyone already knew”
• An exceptional case
• Innocent victims
• Minor infraction
• Names make news
• Naming a victim
• Naming “johns”
• Profile of controversy
• What the media all missed
• Punishing plagiarizers
• Sounding an alarm on AIDS
• Suffer the children
• Anchor’s away
• The day the earth stood still
• Doing your own ethics audit
• Good guys, bad guys and TV news
• Is it just me, or . . . ?
• The Post’s exam answer story
• TV station “teases” suicide
• Yanking Doonesbury
• The year in review
• Colorado media’s option play
• Deadly lesson
• Deciding which critically ill person gets coverage
• When journalists play God . . .
• A delicate balance
• The Fallen Servant
• Handle with care
• It’s the principle, really
• Killing news
• Maybe what seems so right is wrong
• On the line
• Protest and apology after Daily Beacon story
• Red flag for badgering
• Sharing the community’s grief
• The “super-crip” stereotype
• “And then he said *&%*!!!”
• When big is not better
• When the KKK comes calling
• Not the straight story
• Agreeing to disagree
• All in the family
• Family feud
• Author! Author!
• The Bee that roared
• Brewing controversy
• Building barriers
• Other views from librarians
• The ethics of information selling
• Close to home
• Family ties
• How now, sacred cow?
• The ties that bind
• “Like any other story”
• When your newspaper is the news
• Not friendly fire
• Overdraft on credibility?

The problem is the writing

• Written rules can be hazardous
• Project censored, sins of omission and the hardest “W” of all – “why”
• Risking the newsroom’s image
• The Media School

Ethics Case Studies

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Workplace issues

Agreeing to disagree: How one newspaper handles off-hour activities

All in the family: When a journalist’s spouse creates a conflict of interests

Family feud: Handling conflicts between journalists and partners

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Building barriers: The case against financial involvement

Other views from librarians: When interests of client and newsroom conflict

The ethics of information selling: Problems for library reference services

Close to home: When your newsroom is part of the story

Family Ties: When are relationships relationships relevant?

How now, sacred cow?: United Way’s favored treatment by the media

The ties that bind: Publisher’s link to United Way raises questions

“Like any other story”: Can it be when it’s your union vs. your paper?

When your newspaper is the news: Editors discuss their experiences

Not friendly fire: News director at odds with CBS over story

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Project censored, sins of omission and the hardest “W” of all – “why”

Risking the newsroom’s image: How editors, in a good cause, can strain independence

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Case studies are a tool for discussing scientific integrity. Although one of the most frequently used tools for encouraging discussion, cases are only one of many possible tools. Many of the principles discussed below for discussing case studies can be generalized to other approaches to encouraging discussion about research ethics. Cases are designed to confront readers with specific real-life problems that do not lend themselves to easy answers. Case discussion demands critical and analytical skills and, when implemented in small groups, also fosters collaboration (Pimple, 2002). By providing a focus for discussion, cases help trainees to define or refine their own standards, to appreciate alternative approaches to identifying and resolving ethical problems, and to develop skills for analyzing and dealing with hard problems on their own. The effective use of case studies is comprised of many factors, including:

• appropriate selection of case(s) (topic, relevance, length, complexity)
• method of case presentation (verbal, printed, before or during discussion)
• format for case discussion (Email or Internet-based, small group, large group)
• leadership of case discussion (choice of discussion leader, roles and responsibilities for discussion leader)
• outcomes for case discussion (answers to specific questions, answers to general questions, written or verbal summaries)

It should be noted that ethical decision-making is a process rather than a specific correct answer. In this sense, unethical behavior is defined by a failure to engage in the process of ethical decision-making. It is always unacceptable to have made no reasonable attempt to define a consistent and defensible basis for conduct.  

Leading Case Discussions

For the sake of time and clarity of purpose, it is essential that one individual have responsibility for leading the group discussion. As a minimum, this responsibility should include:

• Reading the case aloud.
• Defining, and re-defining as needed, the questions to be answered.
• Encouraging discussion that is "on topic".
• Discouraging discussion that is "off topic".
• Keeping the pace of discussion appropriate to the time available.
• Eliciting contributions from all members of the discussion group.
• Summarizing both majority and minority opinions at the end of the discussion.

How should cases be analyzed?

Many of the skills necessary to analyze case studies can become tools for responding to real world problems. Cases, like the real world, contain uncertainties and ambiguities. Readers are encouraged to identify key issues, make assumptions as needed, and articulate options for resolution. In addition to the specific questions accompanying each case, readers might consider the following questions:

• Who are the affected parties (individuals, institutions, a field, society) in this situation?
• What interest(s) (material, financial, ethical, other) does each party have in the situation? Which interests are in conflict?
• Were the actions taken by each of the affected parties acceptable (ethical, legal, moral, or common sense)? If not, are there circumstances under which those actions would have been acceptable? Who should impose what sanction(s)?
• What other courses of action are open to each of the affected parties? What is the likely outcome of each course of action?
• For each party involved, what course of action would you take, and why?
• What actions could have been taken to avoid the conflict?

If consensus is not possible, then written or oral summaries should reflect majority and minority opinions.  

Is there a right answer?

ACCEPTABLE SOLUTIONS: Most problems will have several acceptable solutions or answers, but it will not always be the case that a perfect solution can be found. At times, even the best solution will still have some unsatisfactory consequences. UNACCEPTABLE SOLUTIONS: While more than one acceptable solution may be possible, not all solutions are acceptable. For example, obvious violations of specific rules and regulations or of generally accepted standards of conduct would typically be unacceptable. However, it is also plausible that blind adherence to accepted rules or standards would sometimes be an unacceptable course of action.

• Bebeau MJ with Pimple KD, Muskavitch KMT, Borden SL, Smith DH (1995): Moral Reasoning in Scientific Research: Cases for Teaching and Assessment . Indiana University.
• Elliott D, Stern JE (1997): Research Ethics - A Reader. University Press of New England, Hanover, NH.
• OEC Resources: Cases
• Ellison, Karin and Karin Wellner. (2013) Research, Ethics, and Society Cases: Discussion Guide , Online Ethics Center.
• The Case Method , Center for Innovation in Teaching & Learning, University of Illinois at Urbana-Champaign
• Herreid CF: National Center for Case Study Teaching in Science, State University of New York at Buffalo. This comprehensive site offers methodology, a case study collection, case study teachers, workshops, and links to additional resources. https://web.archive.org/web/20071006070923/http://ublib.buffalo.edu/libraries/projects/cases/case.html  
• Korenman SG, Shipp AC (1994): Teaching the Responsible Conduct of Research through a Case Study Approach: A Handbook for Instructors. Association of American Medical Colleges, Washington, DC.
• Macrina FL (2005): Scientific Integrity: An Introductory Text with Cases. 3rd edition, American Society for Microbiology Press, Washington, DC.
• National Academy of Sciences (2009): On Being a Scientist: Responsible Conduct in Research . 3rd Edition. Publication from the Committee on Science, Engineering, and Public Policy, National Academy of Sciences, National Academy of Engineering, and Institute of Medicine. National Academy Press, Washington DC.
• Penslar RL, ed. (1995): Research Ethics: Cases and Materials. Indiana University Press, Bloomington, IN.
• Pimple, KD (2002): Using Case Studies in Teaching Research Ethics
• Pimple KD (2002): Using Small Group Assignments in Teaching Research Ethics
• Schrag B, ed. (1996-2007): Graduate Research Ethics: Cases and Commentaries , Volumes 1-7, Association for Practical and Professional Ethics, Bloomington, Indiana.  

The Resources for Research Ethics Education site was originally developed and maintained by Dr. Michael Kalichman, Director of the Research Ethics Program at the University of California San Diego. The site was transferred to the Online Ethics Center in 2021 with the permission of the author.

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This material is based upon work supported by the National Science Foundation under Award No. 2055332. Any opinions, findings, and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the National Science Foundation.

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Case studies.

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• appropriate selection of case(s) (topic, relevance, length, complexity)
• method of case presentation (verbal, printed, before or during discussion)
• format for case discussion (Email or Internet-based, small group, large group)
• leadership of case discussion (choice of discussion leader, roles and responsibilities for discussion leader)
• outcomes for case discussion (answers to specific questions, answers to general questions, written or verbal summaries)

Leading Case Discussions

• Reading the case aloud.
• Defining, and re-defining as needed, the questions to be answered.
• Encouraging discussion that is "on topic".
• Discouraging discussion that is "off topic".
• Keeping the pace of discussion appropriate to the time available.
• Eliciting contributions from all members of the discussion group.
• Summarizing both majority and minority opinions at the end of the discussion.

How should cases be analyzed?

• Who are the affected parties (individuals, institutions, a field, society) in this situation?
• What interest(s) (material, financial, ethical, other) does each party have in the situation? Which interests are in conflict?
• Were the actions taken by each of the affected parties acceptable (ethical, legal, moral, or common sense)? If not, are there circumstances under which those actions would have been acceptable? Who should impose what sanction(s)?
• What other courses of action are open to each of the affected parties? What is the likely outcome of each course of action?
• For each party involved, what course of action would you take, and why?
• What actions could have been taken to avoid the conflict?

Is there a right answer?

• Bebeau MJ with Pimple KD, Muskavitch KMT, Borden SL, Smith DH (1995): Moral Reasoning in Scientific Research: Cases for Teaching and Assessment. Indiana University. http://poynter.indiana.edu/mr/mr-main.shtml
• Elliott D, Stern JE (1997): Research Ethics - A Reader. University Press of New England, Hanover, NH.
• Cases and Scenarios, Online Ethics Center for Engineering and Research, National Academy of Engineering http://www.onlineethics.org/Resources/Cases.aspx
• Foran J (2002): Case Method Website: Teaching the Case Method: Materials for a New Pedagogy, University of California, Santa Barbara. http://www.soc.ucsb.edu/projects/casemethod
• Herreid CF: National Center for Case Study Teaching in Science, State University of New York at Buffalo. This comprehensive site offers methodology, a case study collection, case study teachers, workshops, and links to additional resources. http://ublib.buffalo.edu/libraries/projects/cases/case.html
• Korenman SG, Shipp AC (1994): Teaching the Responsible Conduct of Research through a Case Study Approach: A Handbook for Instructors. Association of American Medical Colleges, Washington, DC.
• Macrina FL (2005): Scientific Integrity: An Introductory Text with Cases. 3rd edition, American Society for Microbiology Press, Washington, DC.
• National Academy of Sciences (1995): On Being a Scientist: Responsible Conduct in Research. 2nd Edition. Publication from the Committee on Science, Engineering, and Public Policy, National Academy of Sciences, National Academy of Engineering, and Institute of Medicine. National Academy Press, Washington DC. http://www.nap.edu/openbook.php?record_id=4917
• National Academy of Sciences (2009): On Being a Scientist: Responsible Conduct in Research. 3rd Edition. Publication from the Committee on Science, Engineering, and Public Policy, National Academy of Sciences, National Academy of Engineering, and Institute of Medicine. National Academy Press, Washington DC. http://www.nap.edu/catalog.php?record_id=12192
• Penslar RL, ed. (1995): Research Ethics: Cases and Materials. Indiana University Press, Bloomington, IN.
• Pimple KD (2002): Using Small Group Assignments in Teaching Research Ethics, The Poynter Center, Indiana University, Bloomington. http://poynter.indiana.edu/tre/kdp-groups.pdf
• Schrag B, ed. (1996): Research Ethics: Cases and Commentaries, Volumes 1-6, Association for Practical and Professional Ethics, Bloomington, Indiana. http://www.onlineethics.org/cms/15333.aspx
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Focus group methodology: some ethical challenges

• Open access
• Published: 16 July 2019
• Volume 53 , pages 3003–3022, ( 2019 )

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• Julius Sim   ORCID: orcid.org/0000-0002-1816-1676 1 &
• Jackie Waterfield   ORCID: orcid.org/0000-0001-9004-7125 2  

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Focus group methodology generates distinct ethical challenges that do not correspond fully to those raised by one-to-one interviews. This paper explores, in both conceptual and practical terms, three key issues: consent; confidentiality and anonymity; and risk of harm. The principal challenge in obtaining consent lies in giving a clear account of what will take place in the group, owing to unpredictability of the discussion and interaction that will occur. As consent can be seen in terms of creating appropriate expectations in the participant, this may therefore be hard to achieve. Moreover, it is less straightforward for the participant to revoke consent than in one-to-one interviews. Confidentiality and anonymity are potentially problematic because of the researcher’s limited control over what participants may subsequently communicate outside the group. If the group discussion encourages over-disclosure by some participants, this problem becomes more acute. Harm in a focus group may arise from the discussion of sensitive topics, and this may be amplified by the public nature of the discussion. A balance should be struck between avoiding or closing down potentially distressing discussion and silencing the voices of certain participants to whom such discussion may be important or beneficial. As a means of addressing the above issues, we outline some strategies that can be adopted in the consent process, in a preliminary briefing session, during moderation of the focus group, and in a subsequent debriefing, and suggest that these strategies can be employed synergistically so as to reinforce each other.

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1 Introduction

The ethics of interview research have been widely discussed. In contrast, ethical aspects of focus group research have received somewhat less detailed attention. Just as the methodology of dyadic interviews may raise ethical issues that do not correspond fully to those raised by one-to-one interviews (Lowton 2018 ), so focus group methodology raises distinct challenges. This paper will examine these challenges, in both conceptual and practical terms, focusing on issues relating to consent, confidentiality, and risk of harm.

1.1 Definition of a focus group

The focus group has its origins in an approach to group interviewing described by Merton et al. ( 1956 ). Since then, it has gained increasing popularity within qualitative research and evaluation. A focus group can be defined broadly as ‘a type of group discussion about a topic under the guidance of a trained group moderator’ (Stewart 2018 : p. 687). Agar and MacDonald ( 1995 ) suggest that a focus group lies somewhere between a meeting (reflecting the fact that it is specifically organized in advance and has a structure) and a conversation (reflecting the fact that the discussion has nonetheless a degree of spontaneity, with individuals picking up on one another’s contributions). It is recommended that data collection, and subsequent analysis, should take account of both the dialogue and the interaction that has occurred within the group (Kitzinger 1994 ; Smithson 2000 ; Halkier 2010 ; Grønkjær et al. 2011 ), and seek to capture the way in which meaning is negotiated and co-produced in the group context (Wilkinson 1998 ). Several detailed accounts of focus group methodology are available (e.g., Morgan 1997 ; Hennink 2007 ; Krueger and Casey 2009 ; Carey and Asbury 2012 ; Barbour 2018 ).

Consent is a central ethical concern in research using human participants. Its specific importance in focus group research is suggested by Green and Hart’s view of this method as one in which participants have a particular vulnerability, as they ‘are not only persuaded by skilled facilitators to disclose intimate views, but also to do this in front of peers’ (Green and Hart 1999 : p. 31).

There are two models of consent: the mental model of consent sees it as the mental state of the person consenting, whereas the performative model sees it as the public act whereby such consent is communicated (Schnüriger 2018 ). On either interpretation, consent serves to legitimize the researcher’s actions. Hence, Walker ( 2018 : p. 131) takes consent to be a form of communication whereby ‘an act that would have been impermissible for some reason is no longer impermissible for that reason.’

The underlying moral ground of consent is centred primarily in the notion of autonomy, on the basis that the consent process can be seen as a means of protecting and supporting autonomous decision making on the part of the research participant (Faden and Beauchamp 1986 ; Beauchamp 2009 ). Additionally, it is supported by the associated principle of respect for persons, which requires one not to use a person merely as a means to an end (Downie and Telfer 1969 ). Consent may be seen as having four essential elements: disclosure (the adequacy of the information given by the researcher); comprehension (the extent to which this information is understood by the participant); competence (the participant’s cognitive or emotional capacity to give or withhold agreement); and voluntariness (the absence of inducement of coercion). Fulfilment of each of these elements is necessary for informed consent to carry its intended moral force (Sim 2010 ).

Lack of information—i.e., inadequate disclosure—is a constraint upon autonomous decision making (Beauchamp 1997 ). The onus is therefore on the researcher to provide a suitable type and quantity of information as a basis for the participant’s choice. In interview-based studies, such information usually states the purpose of the study, gives an outline of the topic(s) to be covered, indicates the way in which the interview will be conducted and how long it is likely to last, draws attention to any potential benefits or risks associated with taking part, and describes what will be done with the data collected. Using the details provided, the participant should be able to foresee or imagine the situation to which he or she is consenting—therefore, the process is perhaps better seen as creating (or perhaps modifying) certain expectations in the mind of the participant rather than as simply the conveying of information . Such expectations will be formed by the manner and context in which information is communicated, and not just by the factual content of this information, and it is therefore more appropriate to think in terms of the message received in the consent process than in terms of the message sent.

2.1 Disclosure and consent

One potentially problematic issue relating to consent in focus groups stems from the degree of disclosure that is possible. In qualitative research generally, the fact that design and methods are to some extent emergent—rather than pre-specified, as they usually are in quantitative research—makes it hard to provide fine-grained detail on what will occur in a study (Wiles 2013 ). This applies even more in focus group research, because what takes place in the group depends in part upon other participants, who may spontaneously raise issues not necessarily intended, or predicted, by the moderator. As Warr ( 2005 : p. 203) puts it, focus groups can be noisy ‘as opinions and anecdotes are shared, challenged, and truncated as participants join in, or drop out of, the discussions taking place.’ Furthermore, individual participants have less control than in a one-to-one interview. Although focus group participants can decline to respond to a particular question—probably more easily than in a one-to-one interview—they may not be able to divert the discussion away from a topic that they find uncomfortable. In effect, they may be unable to foreclose a particular topic in a way that is possible in an individual interview, particularly in the presence of more dominant group members. Footnote 1 Accordingly, to the extent that the discussion in a focus group may take an unanticipated turn, reliance on the disclosure element of consent is thereby weakened.

Turning to the information that is disclosed, as noted earlier this will create particular expectations in participants. Some of these expectations may be inaccurate owing to certain assumptions on the part of participants. For example, they may not appreciate that whilst a focus group may be about exploring a social or health-related problem, it does not necessarily aim to provide solutions to such problems (Carey and Asbury 2012 ). Such a misconception may be encouraged by the ‘consultative’ feel of a group discussion, and the fact that focus groups are sometimes used in service evaluation and quality improvement projects (Smith et al. 1995 ; Schwarz et al. 2000 ). In this connection, for example, Briller et al. ( 2007 –8) argue that it should be made clear to potential participants in a focus group on bereavement that they are not being invited to a support group.

A second issue arises here in relation to the contribution that the participant anticipates making to the group discussion. If the researcher obtains consent on the basis of seeking the participant’s views, there is a responsibility to ensure that the individual has an opportunity to express these views, otherwise the expectation on which consent was based may not be realized. Ensuring that this expectation is fulfilled may require skilful moderation, so as to facilitate participation by all group members. Kitzinger ( 1995 : p. 300) notes that within focus groups ‘the articulation of group norms may silence individual voices of dissent’; however, the moderator may offset this tendency by encouraging contributions from such individuals (Smithson 2000 ). The other side of this coin is that participants should not feel obliged to contribute to a particular line of discussion, and again careful moderation is needed here. Lezaun ( 2007 ) characterizes an underlying principle of the focus group as isegoric —a concern to provide all participants with an equal opportunity to express (or to decline to express) their views. This obligation may be heightened by the expectations created in the consent process.

However, although participants may expect to have their voices heard, they should understand that the predominant insights that emerge from the focus group, and that are subsequently reported, may not reflect their individual views (especially if the issue is controversial, giving a rise to a range of possibly conflicting viewpoints). This is partly because it is not feasible to report each participant’s views, and also because it is not the primary intention of a focus group to do so, given that whilst individual views may be voiced during the meeting, and may be tracked in the analysis (Finch and Lewis 2003 ), these are not readily separable from the interaction occurring within the group. Hence, the analytical focus centres on the co-production of perspectives in the group context, rather than on the perceptions of specific individuals: focus groups ‘are not used to generate multiple accounts of individual perspectives’ (Warr 2005 : p. 201) and are not ‘a collection of individual interviews with comments directed solely through the researcher’ (Finch and Lewis 2003 : p. 171).

A common practice in qualitative research based on interview data is respondent validation (Lincoln and Guba 1985 ). Its purpose is to allow research participants to review and comment on a transcript and/or the researcher’s interpretation of it. In focus group research, however, a decision to provide a transcript to an individual participant entails also providing a written record of other participants’ contributions, as it is hard to extract an individual account from the text in the transcript. Each participant would thereby be provided with a written record of the data provided by the whole group. This may not have been anticipated by other participants, and is therefore something of which they should be made aware in the consent process. Respondent validation would therefore be hard to carry out unless consented to by all participants.

2.2 Consent as revocable

Consent is normally regarded as revocable, such that an individual can withdraw from the study at any point after initially consenting to participate (Faden and Beauchamp 1986 ). It is important to consider the extent to which this option can realistically be exercised in a focus group. Withdrawing from a group discussion is a very public and potentially disruptive act that an individual may find hard to perform. Additionally, in consent documentation the right to withdraw is often stated in terms of not having to give a reason or justification for doing so—this would be difficult in a group situation, as leaving a collective social activity prematurely normally demands some form of explanation. Revoking consent to participation is thus less straightforward in a focus group than in many other research contexts.

This principle that consent is revocable may also be extended to an individual’s data. Just as participants may withdraw their participation in an interview, it is claimed that they may similarly withdraw their data, either from the transcript, or from those parts that are reported as quotations, or from both (Kervin et al. 2006 ). Footnote 2 A withdrawal of consent to the use of quotations presents fewer problems as regards the integrity of a study, as the insights arising from the analysis of the data concerned can still be reported, even though the researcher’s choice of evidence to support them may be restricted. However, withdrawing data from a transcript prior to analysis—which is sometimes proposed (Farquhar 1999 ; Barbour 2018 )—can give rise to particular difficulties in focus group research.

First, if data were to be removed from a transcript prior to analysis, notwithstanding the difficulty of doing so, the inferences that can be drawn from the transcript as a whole may be undermined. Meaning in focus group analysis is derived to a large degree from the dialogue that occurs between participants, rather than from what individual participants, taken singly, have said. The analytical insights that emerge are co-constructed by all the participants, and indeed by the moderator also. Thus, the removal of a section of dialogue may make it hard, or even impossible, to meaningfully interpret subsequent dialogue. Excising material from the transcript may therefore limit the extent to which a coherent analysis can occur.

Second, it follows from the preceding point that if the removal of one person’s data adversely affects the insights that can be gained from a focus group, this affects the extent to which other participants’ contributions to the discussion can play a part in the subsequent analysis. So not only does the withdrawal reduce the contribution of the person whose data they are, but it also denies other participants a full opportunity to make such a contribution.

Probably the only way to resolve this problem is to make it explicit in the consent process that whilst a participant can withdraw from the group, and may ask that his or her data are not quoted when the study is reported, withdrawing data prior to analysis is simply not possible. Accordingly, the inability to retract their data in this way is something to which participants will have consented. There might nonetheless be a concern that limiting individuals’ ability to withdraw their data goes against the fundamental idea that consent is revocable, and thereby fails to respect their autonomy. So, it might be objected that autonomy implies the right to refuse, and that such refusal can occur at any stage in the research process. Three responses can be made to this objection. First, autonomy does not automatically imply that one may change one’s mind. One can make an autonomous choice that one understands to be binding, such as when making a promise or signing a contract. Such a choice is not a sacrifice of autonomy—the commitment that it involves can be seen as an expression of one’s autonomy. Second, given that other participants are likely to have consented to the focus group on the basis of having their views heard and contributing to what is gained from the subsequent analysis of the data, an attempt to respect one individual’s autonomous choice has the consequence of undermining such choice by others. Footnote 3 Third, the detrimental effect on the analysis of withdrawing data in this way is liable to frustrate the moral obligation of the researcher to maximize the value of the insights gained from the study. Together, these three considerations may override what would otherwise be an obligation respect the participant’s wishes. Footnote 4

3 Confidentiality and anonymity

Confidentiality and anonymity are often treated more or less synonymously. Footnote 5 There are, however, important distinctions that can be drawn between these two concepts, and the related notion of privacy. Confidentiality relates to what is done with information once it is in the researcher’s possession, and specifically the extent to which it is disclosed to others. Anonymity, in contrast, is concerned with the attribution of information—can individuals be identified from the data that they provide or from other information relating to them? The fact that some individuals might be concerned about the disclosure of certain information even if they saw no possibility of its being attributed to them—or conversely, that they might not wish their identity as a participant to be disclosed even if no other information relating to them were revealed—demonstrates that confidentiality and anonymity are not equivalent. Whilst confidentiality and anonymity refer to the use and attribution of information, respectively, privacy has to do with initial access to information, and therefore comes into play before considerations of confidentiality and anonymity arise. Footnote 6

As regards data, an assurance can be provided these will be reported anonymously, but if data are declared confidential this would seem to preclude their being directly reported in the form of quotations. Assurances of confidentiality in relation specifically to data are not therefore meaningful (unless anonymity is simply re-expressed in terms of the confidentiality of any identifying information). In terms of information other than data, such as information about the context of the study or biographical details relating to participants, both anonymity and confidentiality are feasible, as such information may either be presented in a form that preserves anonymity, or may not be disclosed at all (particularly if any such disclosure would be hard without thereby breaching anonymity). An important relationship between confidentiality and anonymity is that confidentiality is of greatest concern if anonymity cannot be assured.

The focus group is such that issues of confidentiality and anonymity are acute, especially when the discussion concerns sensitive topics:

The nature of the group setting is such that participants are obliged to express in public what they usually regard as private, and neither the reaction nor the discretion of the group can necessarily be predicted. (Wellings et al. 2000 : p. 256)

3.1 Deductive disclosure and internal confidentiality

An obvious way to preserve anonymity is to ensure that no real names or other directly identifying information are reported. However, individual participants may be identified by other, indirect means through what is referred to as deductive disclosure: ‘A narrative description of what an individual said to a researcher may, with a little collateral information, be sufficient to identify the individual [even] if no clear identifier, such as a name, is attached to the description’ (Boruch et al. 1996 : p. 161). Thus, even if nobody is named, it may be possible to link seemingly innocuous pieces of information together and determine a participant’s identity, particularly in small and/or geographically circumscribed communities. A classic example of this is Carolyn Ellis’s ( 1986 ) ethnographic study of two fishing villages in Chesapeake. Even though no directly identifying information had been used, it emerged that some participants in the study were able to identify themselves and others when the study was published (Ellis 1995 ). Two points about deductive disclosure bear emphasizing. First, the richer and more detailed the data reported, the greater the likelihood of deductive disclosure (Edwards and Weller 2016 ). Second, it may not be clear to the researcher, as an ‘outsider’, which information carries a risk of deductive disclosure; some reported details that appear to have no identifying potential may hold such meaning for others within the community or social group in which the research is centred.

In the context of focus groups, Tolich ( 2009 ) draws a distinction between internal and external confidentiality. Whereas external confidentiality concerns the possible disclosure of information by the researcher, internal confidentiality has to do with information that might be disclosed by members of the group. Footnote 7 Clearly, external confidentiality can normally be assured by the researcher, as he or she is in control of what is reported from the study. Internal confidentiality relies on adherence to ground rules and observance of aspects of the consent process, over both of which the researcher has much more limited control.

It is often recommended that focus groups should be composed of individuals previously unknown to each other, so that pre-existing relationships, and certain assumptions or expectations that these involve, do not influence disclosure (Morgan 1997 ). This assists in preserving anonymity, but if participants are known to one another, their anonymity is clearly harder to maintain. Footnote 8 Additionally, the discussion within the group—and therefore what may be reported—may make reference to existing relationships or a shared history within the group, such that individuals may be recognized by others outside the focus group but within a broader social circle, through deductive disclosure. Bloor et al. ( 2001 : p. 25) suggest that the situation in which participants know one another may lead to a form of third-party breach of confidentiality, whereby a participant may ‘make reference to a personal view or experience of another group member that that individual does not feel comfortable divulging within that particular group setting.’ Kitzinger and Barbour ( 1999 : p. 17) provide an example of such ‘vicarious disclosure’ when noting that in one focus group a participant indicated that another woman had worked as a prostitute. In groups where individuals are already known to one another, information disclosed—and any subsequent failure to observe confidentiality in respect of such information—may have a negative effect on participants’ future relationships (Hofmeyer and Scott 2007 ).

A linked issue to internal confidentiality is that of over-disclosure. Within any form of interview, the rapport that is established between the informant and the researcher, and the efforts of the latter to encourage views or experiences to be expressed, may lead to an individual saying more than he or she might have wished or intended to. Within the specific context of a focus group, not only may the supportive atmosphere that can characterize the group encourage such over-disclosure (Bloor et al. 2001 ), Footnote 9 but the group setting may make it less reparable than in a one-to-one interview. In particular, it is much harder to ‘withdraw’ a comment in the public context of a focus group than in a one-to-one interview (Carey and Asbury 2012 ). Morgan ( 1998 : p. 91) suggests that over-disclosure may be more likely to occur in a focus group involving strangers—‘talking with someone you will never see again can lead to self-disclosure that goes beyond what you would tell your friends or family’—but also argues, in common with Frith ( 2000 ), that the consequences of over-disclosure may be more acute in a focus group in which some or all participants are known to one another, owing to its potential influence on their future relationships. Through careful monitoring of the dialogue and interaction occurring within the group, the moderator can help to minimize the risk of over-disclosure.

The moderator can also minimize deductive disclosure, by omitting certain information about participants in a report, by attributing quotations to categories of participants rather than pseudonymized individuals, or by altering other information that is potentially identifying. In the process, however, the ability of the researcher to present, or the reader to infer, valuable insights from the data may be reduced. Kaiser ( 2009 : p. 1635) notes that ‘unlike changing a specific name, changing additional details to render data unidentifiable can alter or destroy the original meaning of the data.’ Moreover, if measures such as these are taken, it should not be automatically assumed that this is in accordance with participants’ wishes. Whilst they may want their identity to be protected when a study is reported, they may nonetheless disapprove of the use of pseudonyms or categories, such as ‘lone parent’, that might invite negative stereotypes (Corden and Sainsbury 2006 ). Moreover, the unwillingness of some participants to use pseudonyms or to be anonymous may be a means of retaining ‘ownership’ of the meaning of their contributions to the data (Richards and Schwartz 2002 ). Footnote 10 However, although acceding to a request not to use pseudonyms would respect the autonomous wishes of the individual(s) concerned, it might increase the likelihood of deductive disclosure in respect of other participants.

A further means by which anonymity can be protected is to eliminate written records of participants’ true identities. Thus, in a focus group study of relationships between gay and bisexual men in the context of HIV infection and AIDS, O’Brien ( 1993 ) gained approval from an Institutional Review Board for the absence of signed consent forms. Footnote 11

4 Risk of harm

Although in some respects focus groups offer a supportive environment to participants, the group context may also create a sense of public vulnerability:

In individual interviews respondents are protected by the relative intimacy and privacy of the interview situation. In a focus group session, in contrast, respondents are under pressure to perform (and possibly to conform) under the scrutiny of fellow participants. (Ransome 2013 : p. 41)

This form of vulnerability may expose participants to various forms of harm. Thus, social or psychological harm may arise through a breach of confidentiality and/or anonymity. Information that is disclosed may lead to embarrassment, shame, stigmatization, discrimination, disruption of existing social relationships, or adverse employment consequences, and in some cases, participants may face legal action as a result of information that is made public (Warwick 1982 ).

However, harm may potentially arise in other ways than through breaches of confidentiality or anonymity. For example, as noted earlier, participants may mistake a focus group that aims to explore a particular problem for one that seeks to solve such a problem, with the result that unfulfillable hopes are raised and subsequently disappointed. Alternatively, the discussion of particularly sensitive issues within the group context may cause distress or embarrassment. In some situations, such feelings may be directly associated with the topic—such as in a focus group centred on issues to do with sexual behaviour—and may therefore be anticipated. Participants may therefore be considered to have foreseen this possibility when providing consent. Furthermore, as such feelings are likely to result from any discussion of the topic in question, the fact that such discussion occurs within a research context may not raise special concerns. In other instances, however, owing to the way in which the discussion evolves spontaneously, participants may experience distress or embarrassment that they did not predict. The researcher needs to judge whether this is excessive or inappropriate. It is also important to note, however, that focus group discussions can provide a very supportive forum in which participants can express their emotions or anxieties, and thereby have a beneficial rather than a harmful effect. Thus, Ybarra et al. ( 2014 ) found that the use of online focus groups conducted with gay and bisexual adolescents on the topic of HIV prevention led to reduced feelings of isolation and a greater sense of support regarding decisions that some participants had made regarding abstinence. Again, the researcher needs to think carefully about the likely effects on the participants in the group.

Krueger and Casey ( 2009 : p. xiii) maintain that focus group interviewing is ‘about paying attention, being open to what people have to say and being nonjudgmental.’ However, if participants express racist or other discriminatory views, the researcher should consider whether allowing such views to go unchallenged suggests complicity (Longhurst 2016 ). In a one-to-one interview such apparent acquiescence on the part of the researcher may reinforce the views of the individual concerned, but in a focus group it may additionally be construed as some form of public endorsement. In a similar way, harm may arise due to the expression of inaccurate information by a member of the group. The researcher may feel impelled to step out of the researcher role and intervene, or at least address the issue subsequently in a debrief. Hyde et al. ( 2005 ) and Wellings et al. ( 2000 ), for example, talk of the difficulty in staying silent in the face of factually incorrect comments in focus group discussions on HIV, and Kitzinger and Barbour ( 1999 : p. 17) argue that one should not ‘walk away from a group after having silently listened to people convincing each other that HIV can be transmitted by casual contact or that anal intercourse is safer than vaginal intercourse.’

There are two general approaches that the moderator can take in order to avoid or counteract discomfort or distress that may arise from the discussion of sensitive issues: (1) to seek to prevent such issues from arising in the first place, either by declaring them to be ‘off limits’ at the outset, or by averting them by steering the discussion in another direction; and (2) to try to minimize their impact when and if they do arise. The first of these approaches may seem an attractive solution. However, the issues concerned may be integral to the topic of the focus group, and avoiding them at the outset may, at least partly, frustrate the purpose of the research. Additionally, a strategy of avoidance may have the effect of denying certain individuals’ participation. In discussing focus group research in areas related to sexuality, Kitzinger and Farquhar ( 1999 ) suggest that excluding discussion of sexual abuse, and failing to frame any questions on this topic, may marginalize participants who have had such experiences and convey an assumption that nobody could conceivably wish to discuss such issues in a public forum. In a similar way, Kleiber ( 2004 : p. 93) maintains that ‘it is important for the moderator to establish that no opinion or perspective is unacceptable’ and Morgan ( 1992 : p. 185) describes how the moderator can ‘validate the expression of differences within the group.’ The strategy proposed by Kitzinger and Farquhar ( 1999 : p. 170) is that focus group moderators should try to ensure that discussion of sensitive issues is kept at an appropriate level, and ‘should avoid using their power within the research setting either to close off sensitive possibilities or to push them too far.’ Thus, a desire to avoid distress within focus groups—either by foreclosing certain topics at the beginning or by diverting the discussion when an issue arises—should be balanced against the risk of disenfranchising particular categories of individuals or censoring certain views as unacceptable.

The second approach—dealing with potential distress as it arises—relies on a prompt response on the part of the moderator. Owen ( 2001 : p. 657) provides an example from her research on women’s mental health problems:

Whilst the women were permitted to discuss their painful and emotional experiences, the discussion was moved on if it was evident that the women were becoming distressed. As far as possible this was done sensitively by waiting for a suitable break in the self disclosure, openly acknowledging the woman’s contribution, and posing another question to the group. More general questions were usually introduced at the end of each group in an attempt to lighten the atmosphere.

In some instances, distress can be prevented at an earlier stage, by managing the composition of the group. Thus, Bloor et al. ( 2001 : p. 35) advise avoiding groups made up of ‘individuals with such conflicting views that the resultant discussion might cause distress to individual members.’ It would, however, be important to balance this strategy against the need to obtain whatever range of views is important for the aims of the research.

4.1 Challenges in assessing harm

Underlying assessment of the risk of harm are three fundamental difficulties. The first is that both predicting and identifying harm are not straightforward in qualitative social research. In medical research, by way of contrast, the nature of possible harms may be foreseen—for example, known complications or side-effects of a pharmacological or surgical intervention. Furthermore, such effects may be recognized promptly, as participants may be under prolonged observation or monitoring by clinicians who know what to look for. In qualitative research, however, whilst some potential harms may be obvious and predictable, foreseeing others might depend on knowledge of individual participants’ psychological characteristics or biography—information that the researcher may not possess, at least initially. It is important for the researcher to be alert to both verbal and nonverbal signs of potentially harmful emotions (Kavanaugh and Ayres 1998 ). However, in some respects, harm may be less readily identified in a focus group than in a face-to-face interview: firstly, because the public context of the group may make participants less willing to display feelings of distress or embarrassment, and secondly because the moderator’s attention is less closely focused on a particular participant than in a one-to-one interview.

The second difficulty springs from the fact that, as Wiles ( 2013 ) points out, apparently innocuous topics can unexpectedly cause some individuals distress, and as Hammersley and Traianou ( 2012 ) indicate, what is a harm to one person may be a benefit to another. This has particular relevance in a group setting. For example, if the discussion in a focus group were to turn to matters of bereavement or sexual harassment, this might cause distress to some participants who had had such experiences, but for others in the group with these experiences the discussion might be welcome, by virtue of providing an opportunity to express feelings that they are rarely able to share and to seek support or validation from others (Dyregrov 2004 ; Butler et al. 2018 ); a similar observation by Ybarra et al. ( 2014 ) was noted earlier. Madriz ( 1998 : p. 116) refers to this notion of validation when discussing her research on fear of crime with Latina women, and suggests that focus groups may provide ‘collective testimonies… [that] provide women with the possibility of breaking the wall of silence that has suppressed the expression of their ideas and emotions.’ Similarly, avoiding reference to sexual orientation or gender identity may prevent discomfort to some group members, but for any who are members of the LGBT community this may eliminate ‘the opportunity for the particular needs of those individuals to be identified’ (Dodd 2009 : p. 478). It should also be borne in mind that a focus group may draw on its own resources to limit potential harm (Kitzinger and Barbour 1999 ; Barbour 2018 ), especially if participants are previously known to one another and can enlist existing supportive relationships.

The third difficulty is a conceptual one—that of distinguishing ‘harm’ from other unpleasant feelings and experiences, and thereby determining whether a moral wrong has been committed. Footnote 12 Hitherto, we have used ‘harm’ in fairly broad sense. A more specific definition comes from Feinberg ( 1984 : p. 34), who defines a harm as the ‘thwarting, setting back, or defeating of an interest’ (p. 33), where one’s interests comprise ‘all those things in which one has a stake.’ Accordingly, ‘[o]ne person harms another… by invading, and thereby thwarting or setting back, his interest’ (p. 34). These interests represent important aspects of a person’s well-being. However, not everything that is disliked or gives rise to negative emotions is harmful. Here, Feinberg refers to what he calls offences:

Passing annoyance, disappointment, disgust, embarrassment, and various other disliked conditions such as fear, anxiety, and minor (“harmless”) aches and pains, are not in themselves necessarily harmful. (Feinberg 1985 : p. 1)

A harm, on these definitions, is clearly harder to justify morally than an offence. Indeed, an offence may promote rather than undermine a person’s interest. If a discussion in a focus group causes a person to feel distress or embarrassment, this may be cathartic or lead to greater self-insight, which would presumably be in that person’s interest. Thus, Hutchinson et al. ( 1994 ) and Cook and Bosley ( 1995 ) outline some of the psychological benefits that may potentially occur through participating in interview research, even on sensitive topics, and Hollway and Jefferson ( 2013 : pp. 90–91) point to a psychoanalytical model of research whose theoretical principles:

stress that well-being depends on making the causes of distress conscious… According to this model, it is not necessarily harmful if research raises painful and distressing experience, though it may be discomforting.

Accordingly, it should not be assumed that all expressions of embarrassment, distress or other negative feelings within a focus group are necessarily harms and therefore a matter of moral concern. Footnote 13

4.2 Justifying harm

A common means of justifying risk of harm in research is to point to a greater countervailing benefit that may likely be gained through a study. Footnote 14 This rests upon the assumption that harms and benefits are commensurable, and thereby capable of being offset, the one against the other (Macintyre 1982 ). There are, however, a number of important caveats to this justification. First, the magnitude of some harms may be so great that no resulting benefits could justify them—though such harms might be very rare in social research (Diener and Crandall 1978 ). Second, steps must previously have been taken to minimize the risk of harm, and it must be inherent to the topic and the nature of the research; risk of harm due to poor conduct of a study—such as insensitively worded questions or inattention to participants’ emotional reactions—cannot be justified. Third, a precondition for any justification is that participants should have been informed about, and consented to, the possibility of harm (to the extent to which previously noted limitations of the consent process allow). The harms in question, if they occur, must be assumed by participants, not imposed upon them. For example, Iphofen ( 2009 : p. 54) suggests that a possible social harm resulting from focus group participation might be that:

the time taken to invest, say, in attending a focus group… may lead to participants being unable to attend a regular social event in their community or family which is vital to their acceptance and/or status within that community.

If a justification were required for this, it might point to the participant’s autonomous choice of one activity (the group discussion) over another (the social event).

Fourth, in addition to taking account of the relative magnitude of harms and benefits, these should also be weighed in probabilistic terms; using a remote chance of benefit to justify a likely risk of harm, other things being equal, would be questionable. Fifth, the type of harm and benefit should be considered. If a focus group study were to be carried out on aspects of self-harm in adolescents, the findings might have tangible medical or social benefits for adolescents in general, even if not necessarily for the specific participants in the study. Conversely, the same type of practical benefit might not be identifiable in a study on a topic where a more theoretical understanding is sought, yielding a more abstract value. Justifying a risk of harm in the second example might be harder than in the first. Footnote 15

Finally, at a more conceptual level, such a weighing of harms against benefits—except when the harms and benefits affect the same individuals—relies to a large measure on an aggregate view; the fact that benefits, averaged across certain individuals, outweigh harms, averaged over other individuals, serves to justify these harms. Such a notion underlies Hennink’s view that focus group researchers ‘need to continually weight the potential social benefits of the information sought against the potential risk of harm to participants’ (Hennink 2007 : p. 38). A different view of the matter would suggest that the welfare of individuals cannot so readily be subsumed under considerations of overall social benefit, and would reject, or at least set limits to, such a trade-off between harms and benefits. This view would suggest that harms and benefits should be individuated—such that it matters whose harm it is and whose benefit it is, and these cannot readily be traded off between individuals. Footnote 16

Thus, whilst harms and benefits may in principle be commensurable, they may less readily be aggregated across individuals. For example, a series of focus groups might be run with parents who had suffered the perinatal loss of a child. If it were anticipated that some participants might become acutely distressed, this might be justified if it were believed that such feelings might be cathartic for the individuals in question and assist in the grieving process. The risk of harm would be balanced against the possibility of benefit for those same individuals. If, however, the justification rested upon future improvements in policy and practice in perinatal care—affecting future parents—the fact that harms and benefits would be distributed between, not within, individuals makes the process of justification more challenging.

5 Practical strategies

There are a number of ways in which the potentially problematic issues outlined hitherto can be avoided or mitigated, and some have already been touched upon. These strategies will be explored further in relation to the consent process, briefing prior to the focus group, the conduct and moderation of the focus group, and debriefing after the focus group.

The consent process : If the researcher provides information with a suitable level of detail and with due clarity, in principle this will help focus group participants to frame appropriate expectations of what will occur during the discussion. The purpose of the focus group can be explained and examples given of the sorts of questions that will be asked. Clarification can also be provided on what will be done with the data to be collected and the steps to be taken to preserve confidentiality and/or anonymity. Thus, certain assurances can be given, though these can strictly only relate to those aspects of the focus group over which the researcher has a degree of influence (Carey and Asbury 2012 ). Morgan ( 1998 ) and Tolich ( 2009 ) provide suggested content for informed consent documentation. Briefing: In addition to giving information in advance of a focus group, researchers normally discuss and negotiate a set of ground rules immediately prior to starting the discussion (Kevern and Webb 2001 ; Kleiber 2004 ; Breen 2006 ), especially in the case of sensitive topics (Farquhar 1999 )—though Krueger ( 1998 : p. 23) suggests that using a less formal term than ‘ground rules’ may be helpful so as not to stifle discussion. The researcher can emphasize the public nature of a focus group and the need for confidentiality and anonymity, and provide guidance on subjects that might be felt unsuitable to be raised during the discussion, subject to the caveats discussed earlier. The briefing also allows participants’ expectations of the group to be managed, for example by pointing out that the group seeks to discuss a particular health or social problem, not to provide a solution to such a problem. Importantly, the collective nature of the briefing allows the individual to reflect on his or her decision to take part in a situation that is closer than the formal consent process to the context of such participation. Furthermore, if at this point a participant has reconsidered the decision to take part in the study, the briefing can create an opportunity to withdraw less obtrusively than once the discussion has begun. Conduct of the focus group: Although the moderator’s influence over what happens in a focus group may be limited, he or she can nonetheless try to ensure that all members of the group have an opportunity to contribute to the discussion, without being under pressure to do so if unwilling, and that one or more individuals do not dominate the group. Additionally, the moderator can be alert to distress, breaches of confidentiality, or over-disclosure, and seek to turn the discussion in another direction if appropriate. Footnote 17 If sensitive or emotionally difficult topics have been discussed, it may be helpful to finish the discussion on a more neutral or positive note (Finch and Lewis 2003 ; Briller et al. 2007 –8). It is also important to ensure, when discussion of such sensitive topics is intended or anticipated, that the moderator can respond appropriately. Even if not qualified to provide psychological therapy, the moderator can offer emotional support (Rosenblatt 1995 ), and can take appropriate steps to ensure prompt access to qualified therapy through clinical referral (Carey and Asbury 2012 ). Debriefing : After the focus group has finished, and its content summarized to participants, the moderator can reiterate key messages around confidentiality and anonymity, and clarify or comment upon any potentially sensitive or problematic issues that were raised during the discussion, where it was not appropriate to do so at the time. Participants can also be invited to discuss their reactions to such issues (Smith 1995 ). The moderator can stay in the room for a while at the end of the focus group, or otherwise make him- or herself available, to give individual participants the opportunity to address any issues or concerns (Bloor et al. 2001 ; Sherriff et al. 2014 ).

The first two of the above approaches—the process of obtaining consent and the briefing prior to the discussion—are means of providing information and giving certain assurances as to what is and what is not intended or foreseen. Martin Tolich, however, is pessimistic regarding the researcher’s ability to provide assurances to focus group participants:

…let the researcher, the participants and the ethics committee beware that the only ethical assurance that can be given to focus group participants is that there are few ethical assurances. (Tolich 2009 : p. 99)

He acknowledges the role of the moderator, but suggests that one should not rely unduly on the moderator’s skill in controlling the group, and has similar reservations regarding the use of ground rules or a debriefing session. Instead, Tolich’s central strategy is one of ‘caveat emptor’:

Taking part in focus groups involves risk and the participants’ [sic] must have these risks identified for them, explicitly, and then be willing to absorb those risks. (Tolich 2009 : p. 106) Footnote 18

In Tolich’s approach to the ethics of focus groups, the principal emphasis is accordingly on the quality of the consent process and participants’ autonomous assumption of certain risks, rather than on measures to mitigate ethical problems as they arise:

Ethical assurances, rather than safety techniques, should be at the fore. These assurances should be communicated to the potential participant in the recruitment phase of the research with such transparency that they allow the research participant to read in advance how the researcher plans to contend with the two endemic ethical flaws [relating to confidentiality and consent] in focus group research. Transparency is manifest in both an explicit description of the endemic flaws and an honest statement on the limitations of any ethical assurances. (Tolich 2009 : p. 106)

On this basis, Tolich provides detailed suggestions as to the information that should be included in an informed consent form, building on earlier suggestions by Morgan ( 1998 ).

However, as a general strategy, it may be unwise to rely so heavily on the consent process as a means of addressing ethical challenges in focus groups. First, as an empirical issue, providing information to participants as part of the consent process is only of value if this information is understood and recalled, and if it creates appropriate expectations of what will take place in the focus group. However, as noted earlier, the specific issues that are discussed in a focus group, and the way in which participants interact and behave during the discussion, are to a large degree unpredictable, and participants’ expectations based on prior information may not be realized. Moreover, whilst its generalizability to social research may be questioned, evidence from the medical literature of poor recall and comprehension of consent information may caution us against over-reliance on some aspects of the consent process (Corrigan 2003 ; Dawson 2009 ). Second, at a more philosophical level, whilst consent may be a necessary condition for involving an individual in a study, it is not a sufficient condition—the researcher’s moral responsibility does not end with ensuring that participants make an informed and autonomous choice as regards participation. The focus group participant may well consent to the possibility of distress during the discussion or the risk of a breach of confidentiality, but there are separate obligations on the part of the researcher—based on an independent notion of non-maleficence—to mitigate such risks as the discussion takes place. If these obligations are not discharged, the involvement of the participant may be morally unjustified, regardless of the apparent quality of the consent process.

A more effective approach, perhaps, is to enlist all four of the strategies outlined above in approximately equal measure, so that one strategy may reinforce, or compensate for, another in a synergistic manner. In this way, the pre-discussion briefing can reiterate and re-emphasize information given in an information sheet as part of the consent process, and address any questions that may have subsequently arisen in participants’ minds. The briefing can also raise issues regarding the conduct of the group—including ground rules—that might be less effectively conveyed by an information sheet. Moreover, such ground rules may be more effective if mutually negotiated by the group, rather than being stated in the consent documentation. Similarly, raising such issues at the level of the group, as opposed to when raised at an individual level in the consent process, may place them more clearly in the context to which they apply.

The process of moderation can attempt to deal with sensitive and potentially distressing issues that arise—perhaps unpredictably—through the dynamics of the interaction within the focus group. For example, Owen ( 2001 ) relates an incident in which a woman unexpectedly gave an account of her partner’s suicide and her feelings of loss and betrayal, and Seymour et al. ( 2002 : p. 523) relate an incident in a focus group on end-of-life care where a woman stated ‘I’ve done euthanasia’—in both cases the moderator felt the need to take action to deal with the situation. If appropriate, at certain junctures in the discussion the moderator can also give reminders of matters of confidentiality outlined in the consent documentation and encourage observance of agreed ground rules. Finally, a debriefing after the group discussion can not only reinforce elements within each of the previous strategies, but may also provide an opportunity for individual participants to raise concerns that may have been difficult to address during the group discussion.

6 Conclusion

In this paper we have attempted to identify and analyse some of the principal ethical issues that may arise within focus group research, and suggest practical approaches to managing these issues. Many of these issues stem from, or are given a particular emphasis by, the nature of focus group methodology. Thus, the spontaneous and at least partially unpredictable nature of the dialogue between participants may give rise to problems to do with harm or confidentiality, and also limits the extent to which such problems can be identified in advance during the consent process. The dynamics within the group may lead to some individuals dominating the discussion and thereby denying the expression of others’ views. The group context also complicates matters by creating multiple, intersecting interests. What may cause distress to one participant may give voice to, or provide a sense of validation to, another participant. Similarly, steps taken to protect anonymity or confidentiality in respect of some participants may undermine the contribution of others. Further issues arise when a focus group takes place within the context of existing social or professional relationships.

Some of the ethical challenges posed by focus groups can be addressed through the consent process, provided that appropriate expectations have been expressed and received, but steps should also be taken to supplement and reinforce these issues closer to the actual context of the focus group: in a briefing immediately prior to the discussion, during the discussion itself, and in a debriefing immediately after the focus group. However, the dynamic context of the focus group demands more than this. The moderator needs to make on-the-spot judgements; for example, on whether or not some individuals are at risk of harm from the nature of the discussion taking place, or on whether a particular topic can be closed down without thereby depriving some participants of their voice.

It is commonly recommended that participants within a focus group should be homogeneous (Morgan 1997 ; Krueger and Casey 2009 ), so as to minimize differences in status or power and to prevent the discussion being dominated by higher-status members of the group. However, if such differences in status or power nonetheless occur, they may further limit the ability of some members to influence the discussion.

In both cases, unless all dialogue in the focus group has been accurately ascribed to identifiable individuals—which may be challenging, given Warr’s view ( 2005 : p. 203) that focus group interaction may sometimes be ‘disorderly and noisy’—it may not be possible to omit the data relating to any one such individual. Perhaps a more serious problem is that another’s data could be removed by mistake.

A similar issue may arise with regard to the audio-recording of the group discussion. Hennink ( 2007 : p. 36) suggests that participants should be told that they can ask for audio-taping equipment to be turned off at any time; any such request may not reflect the wishes of all participants.

In contrast, it might be argued that considerably more significant interests are at stake in terms of protecting a participant’s anonymity, and it would therefore be much harder to justify opposing a request for quotations to be withheld from the report. It should also be noted that a refusal to withdraw data on the basis of what was stated by the researcher in the consent process requires that this message had been clearly explained and was understood.

For example: ‘Participants need to be assured of the confidentiality and anonymity of their comments’ (Hennink 2007 : p. 41); ‘participants must be guaranteed that they will not be identified by name or otherwise, referred to as anonymity or confidentiality’ (Lincoln 2009 : p. 152); ‘The primary method researchers use to preserve anonymity and confidentiality is the use of pseudonyms for participants and also for the location of the research. In addition, other practices, such as changing the reported characteristics of participants (such as gender or occupation) are also used by some researchers to conceal identities and thereby maintain the confidentiality of the data provided by participants.’ (Crow and Wiles 2008 , p. 2); ‘Confidentiality means we are obliged to protect each participant’s identity, places and the location of the research’ (Ryen 2016 : p. 33).

Tolich ( 2016 ) argues against the usefulness of the concept of anonymity in qualitative research. However, he appears to construe anonymity solely in terms of what the researcher knows about the participant’s identity, whereas the more pressing issue is what others know. In focus groups, and in qualitative research more generally, the core issue is not whether data are gathered anonymously from participants, but whether they are stored and presented anonymously.

Rather confusingly, Tolich defines internal confidentiality in a different way in an earlier paper (Tolich 2004 : p. 101), as: ‘the ability for research subjects involved in the study to identify each other in the final publication of the research.’ This interpretation is closer to the notion of deductive disclosure, and we will follow the definition offered in the later paper (Tolich 2009 ).

A common means of preserving anonymity is to use pseudonyms or other anonymized identifiers. If participants in a focus group are hitherto unknown to one another, pseudonyms can be used within the group discussion (Wong, 2008 ); this anonymizes both the dialogue and the resulting transcript. Using pseudonyms in a focus group where participants are already acquainted effectively only serves to anonymize the transcript and may lead to a rather unnatural flow of dialogue. If data have not yet been anonymized, at the point of analysis pseudonyms or other anonymous identifiers can be substituted for real names, and these can be carried forward into the written research report.

Guest et al. ( 2017 ) found that certain sensitive themes or personal disclosures were more likely in focus groups than in individual interviews.

Perry ( 2011 ) points out that, in some communities, the changing of names may have negative cultural associations. Writing about social research in Sudan, she notes that forced name-changing was historically a means of repressing minorities.

The focus in this section has been on the protection of confidentiality. In some circumstances, however, there may be a moral or legal obligation on researchers to breach confidentiality by disclosing certain information—e.g., a moral obligation to protect a third party from harm, or a legal obligation to report certain types of illegal activity (Bennett 2007 ). Such possibilities should, wherever possible, be included in the information given during the consent process.

Thus, on this definition to harm somebody is to wrong him or her, but to cause that person distress does not necessarily do so.

An additional question that we do not address here, for reasons of space, is causal responsibility for harm. Hammersley and Traianou ( 2012 ) provide a detailed discussion of this issue.

We used this argument earlier as part of our justification of resisting any requests for data to be withdrawn prior to analysis.

Crucially, this is not to denigrate or underestimate the value of theoretical understanding, but merely to suggest that such benefit may have limited force in specific relation to the justification of risk of harm. See Hammersley and Traianou ( 2012 ) and Hammersley and Atkinson ( 2019 ) for a defence of the non-instrumental value of qualitative research.

The first line of moral reasoning outlined here is essentially a consequentialist one and the second essentially a deontological one (Scheffler 1982 ; Kamm 2013 ).

Seymour et al. ( 2002 ) describe how presenting potentially sensitive topics in a PowerPoint presentation assisted the moderator in switching the group’s focus if the discussion became deeply personal.

He reflects this view in the information that he proposes as part of the consent documentation provided to participants: ‘There are risks in taking part in focus group research and taking part assumes that you are willing to assume those risks’ (Tolich 2009 : p. 103).

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

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

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

Dónal O’Mathúna and Ron Iphofen .

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Published online: November 3, 2022.

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

1.1. Judging the Ethics of Research

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

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

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

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

1.2. The Case for Cases

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

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

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

1.3. Research Design and Causal Inference

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

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

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

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

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

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

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

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

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

1.4. Devil’s in the Detail

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

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

1.5. Cases and Policymaking

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

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

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

1.6. The Moral Gain

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

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

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

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

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

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

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

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

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

1.7. Into the Future

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

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

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

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

• Cite this Page O’Mathúna D, Iphofen R. Making a Case for the Case: An Introduction. 2022 Nov 3. In: O'Mathúna D, Iphofen R, editors. Ethics, Integrity and Policymaking: The Value of the Case Study [Internet]. Cham (CH): Springer; 2022. Chapter 1. doi: 10.1007/978-3-031-15746-2_1
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In this Page

• Judging the Ethics of Research
• The Case for Cases
• Research Design and Causal Inference
• Devil’s in the Detail
• Cases and Policymaking
• The Moral Gain
• Into the Future

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Ethics Ethics Case Studies

The SPJ Code of Ethics is voluntarily embraced by thousands of journalists, regardless of place or platform, and is widely used in newsrooms and classrooms as a guide for ethical behavior. The code is intended not as a set of "rules" but as a resource for ethical decision-making. It is not — nor can it be under the First Amendment — legally enforceable. For an expanded explanation, please follow this link .

For journalism instructors and others interested in presenting ethical dilemmas for debate and discussion, SPJ has a useful resource. We've been collecting a number of case studies for use in workshops. The Ethics AdviceLine operated by the Chicago Headline Club and Loyola University also has provided a number of examples. There seems to be no shortage of ethical issues in journalism these days. Please feel free to use these examples in your classes, speeches, columns, workshops or other modes of communication.

Kobe Bryant’s Past: A Tweet Too Soon? On January 26, 2020, Kobe Bryant died at the age of 41 in a helicopter crash in the Los Angeles area. While the majority of social media praised Bryant after his death, within a few hours after the story broke, Felicia Sonmez, a reporter for The Washington Post , tweeted a link to an article from 2003 about the allegations of sexual assault against Bryant. The question: Is there a limit to truth-telling? How long (if at all) should a journalist wait after a person’s death before resurfacing sensitive information about their past?

A controversial apology After photographs of a speech and protests at Northwestern University appeared on the university's newspaper's website, some of the participants contacted the newspaper to complain. It became a “firestorm,” — first from students who felt victimized, and then, after the newspaper apologized, from journalists and others who accused the newspaper of apologizing for simply doing its job. The question: Is an apology the appropriate response? Is there something else the student journalists should have done?

Using the ‘Holocaust’ Metaphor People for the Ethical Treatment of Animals, or PETA, is a nonprofit animal rights organization known for its controversial approach to communications and public relations. In 2003, PETA launched a new campaign, named “Holocaust on Your Plate,” that compares the slaughter of animals for human use to the murder of 6 million Jews in WWII. The question: Is “Holocaust on Your Plate” ethically wrong or a truthful comparison?

Aaargh! Pirates! (and the Press) As collections of songs, studio recordings from an upcoming album or merely unreleased demos, are leaked online, these outlets cover the leak with a breaking story or a blog post. But they don’t stop there. Rolling Stone and Billboard often also will include a link within the story to listen to the songs that were leaked. The question: If Billboard and Rolling Stone are essentially pointing readers in the right direction, to the leaked music, are they not aiding in helping the Internet community find the material and consume it?

Reigning on the Parade Frank Whelan, a features writer who also wrote a history column for the Allentown, Pennsylvania, Morning Call , took part in a gay rights parade in June 2006 and stirred up a classic ethical dilemma. The situation raises any number of questions about what is and isn’t a conflict of interest. The question: What should the “consequences” be for Frank Whelan?

Controversy over a Concert Three former members of the Eagles rock band came to Denver during the 2004 election campaign to raise money for a U.S. Senate candidate, Democrat Ken Salazar. John Temple, editor and publisher of the Rocky Mountain News, advised his reporters not to go to the fundraising concerts. The question: Is it fair to ask newspaper staffers — or employees at other news media, for that matter — not to attend events that may have a political purpose? Are the rules different for different jobs at the news outlet?

Deep Throat, and His Motive The Watergate story is considered perhaps American journalism’s defining accomplishment. Two intrepid young reporters for The Washington Post , carefully verifying and expanding upon information given to them by sources they went to great lengths to protect, revealed brutally damaging information about one of the most powerful figures on Earth, the American president. The question: Is protecting a source more important than revealing all the relevant information about a news story?

When Sources Won’t Talk The SPJ Code of Ethics offers guidance on at least three aspects of this dilemma. “Test the accuracy of information from all sources and exercise care to avoid inadvertent error.” One source was not sufficient in revealing this information. The question: How could the editors maintain credibility and remain fair to both sides yet find solid sources for a news tip with inflammatory allegations?

A Suspect “Confession” John Mark Karr, 41, was arrested in mid-August in Bangkok, Thailand, at the request of Colorado and U.S. officials. During questioning, he confessed to the murder of JonBenet Ramsey. Karr was arrested after Michael Tracey, a journalism professor at the University of Colorado, alerted authorities to information he had drawn from e-mails Karr had sent him over the past four years. The question: Do you break a confidence with your source if you think it can solve a murder — or protect children half a world away?

Who’s the “Predator”? “To Catch a Predator,” the ratings-grabbing series on NBC’s Dateline, appeared to catch on with the public. But it also raised serious ethical questions for journalists. The question: If your newspaper or television station were approached by Perverted Justice to participate in a “sting” designed to identify real and potential perverts, should you go along, or say, “No thanks”? Was NBC reporting the news or creating it?

The Media’s Foul Ball The Chicago Cubs in 2003 were five outs from advancing to the World Series for the first time since 1945 when a 26-year-old fan tried to grab a foul ball, preventing outfielder Moises Alou from catching it. The hapless fan's identity was unknown. But he became recognizable through televised replays as the young baby-faced man in glasses, a Cubs baseball cap and earphones who bobbled the ball and was blamed for costing the Cubs a trip to the World Series. The question: Given the potential danger to the man, should he be identified by the media?

Publishing Drunk Drivers’ Photos When readers of The Anderson News picked up the Dec. 31, 1997, issue of the newspaper, stripped across the top of the front page was a New Year’s greeting and a warning. “HAVE A HAPPY NEW YEAR,” the banner read. “But please don’t drink and drive and risk having your picture published.” Readers were referred to the editorial page where White explained that starting in January 1998 the newspaper would publish photographs of all persons convicted of drunken driving in Anderson County. The question: Is this an appropriate policy for a newspaper?

Naming Victims of Sex Crimes On January 8, 2007, 13-year-old Ben Ownby disappeared while walking home from school in Beaufort, Missouri. A tip from a school friend led police on a frantic four-day search that ended unusually happily: the police discovered not only Ben, but another boy as well—15-year-old Shawn Hornbeck, who, four years earlier, had disappeared while riding his bike at the age of 11. Media scrutiny on Shawn’s years of captivity became intense. The question: Question: Should children who are thought to be the victims of sexual abuse ever be named in the media? What should be done about the continued use of names of kidnap victims who are later found to be sexual assault victims? Should use of their names be discontinued at that point?

A Self-Serving Leak San Francisco Chronicle reporters Mark Fainaru-Wada and Lance Williams were widely praised for their stories about sports figures involved with steroids. They turned their investigation into a very successful book, Game of Shadows . And they won the admiration of fellow journalists because they were willing to go to prison to protect the source who had leaked testimony to them from the grand jury investigating the BALCO sports-and-steroids. Their source, however, was not quite so noble. The question: Should the two reporters have continued to protect this key source even after he admitted to lying? Should they have promised confidentiality in the first place?

The Times and Jayson Blair Jayson Blair advanced quickly during his tenure at The New York Times , where he was hired as a full-time staff writer after his internship there and others at The Boston Globe and The Washington Post . Even accusations of inaccuracy and a series of corrections to his reports on Washington, D.C.-area sniper attacks did not stop Blair from moving on to national coverage of the war in Iraq. But when suspicions arose over his reports on military families, an internal review found that he was fabricating material and communicating with editors from his Brooklyn apartment — or within the Times building — rather than from outside New York. The question: How does the Times investigate problems and correct policies that allowed the Blair scandal to happen?

Cooperating with the Government It began on Jan. 18, 2005, and ended two weeks later after the longest prison standoff in recent U.S. history. The question: Should your media outlet go along with the state’s request not to release the information?

Offensive Images Caricatures of the Prophet Muhammad didn’t cause much of a stir when they were first published in September 2005. But when they were republished in early 2006, after Muslim leaders called attention to the 12 images, it set off rioting throughout the Islamic world. Embassies were burned; people were killed. After the rioting and killing started, it was difficult to ignore the cartoons. Question: Do we publish the cartoons or not?

The Sting Perverted-Justice.com is a Web site that can be very convenient for a reporter looking for a good story. But the tactic raises some ethical questions. The Web site scans Internet chat rooms looking for men who can be lured into sexually explicit conversations with invented underage correspondents. Perverted-Justice posts the men’s pictures on its Web site. Is it ethically defensible to employ such a sting tactic? Should you buy into the agenda of an advocacy group — even if it’s an agenda as worthy as this one?

A Media-Savvy Killer Since his first murder in 1974, the “BTK” killer — his own acronym, for “bind, torture, kill” — has sent the Wichita Eagle four letters and one poem. How should a newspaper, or other media outlet, handle communications from someone who says he’s guilty of multiple sensational crimes? And how much should it cooperate with law enforcement authorities?

A Congressman’s Past The (Portland) Oregonian learned that a Democratic member of the U.S. Congress, up for re-election to his fourth term, had been accused by an ex-girlfriend of a sexual assault some 28 years previously. But criminal charges never were filed, and neither the congressman, David Wu, nor his accuser wanted to discuss the case now, only weeks before the 2004 election. Question: Should The Oregonian publish this story?

Using this Process to Craft a Policy It used to be that a reporter would absolutely NEVER let a source check out a story before it appeared. But there has been growing acceptance of the idea that it’s more important to be accurate than to be independent. Do we let sources see what we’re planning to write? And if we do, when?

SPJ News –  SPJ calls for action by journalists against gag rules after key legal win –  SPJ Foundation awards over $45,000 in grants to seven initiatives and journalism programs –  SPJ announces 2023 Mark of Excellence National Winners

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• Topic 1. Contemporary issues relating to conditions conducive both to the spread of terrorism and the rule of law
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University Module Series: Integrity & Ethics

Module 12: integrity, ethics and law.

  This module is a resource for lecturers  

Case studies.

Choose one or more of the following case studies and lead a discussion which allows students to address and debate issues of integrity, ethics and law. If time allows, let the students vote on which case studies they want to discuss.

For lecturers teaching large classes, case studies with multiple parts and different methods of solution lend themselves well to the group size and energy in such an environment. Lecturers can begin by having students vote on which case study they prefer. Lecturers could break down analysis of the chosen case study into steps which appear to students in sequential order, thereby ensuring that larger groups stay on track. Lecturers may instruct students to discuss questions in a small group without moving from their seat, and nominate one person to speak for the group if called upon. There is no need to provide excessive amounts of time for group discussion, as ideas can be developed further with the class as a whole. Lecturers can vary the group they call upon to encourage responsive participation.

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Gabriela Salinas and Jeeva Somasundaram

Roula Khalaf, Editor of the FT, selects her favourite stories in this weekly newsletter.

In April this year, Hein Schumacher, chief executive of Unilever, announced that the company was entering a “new era for sustainability leadership”, and signalled a shift from the central priority promoted under his predecessor , Alan Jope.

While Jope saw lack of social purpose or environmental sustainability as the way to prune brands from the portfolio, Schumacher has adopted a more balanced approach between purpose and profit. He stresses that Unilever should deliver on both sustainability commitments and financial goals. This approach, which we dub “realistic sustainability”, aims to balance long- and short-term environmental goals, ambition, and delivery.

As a result, Unilever’s refreshed sustainability agenda focuses harder on fewer commitments that the company says remain “very stretching”. In practice, this entails extending deadlines for taking action as well as reducing the scale of its targets for environmental, social and governance measures.

Such backpedalling is becoming widespread — with many companies retracting their commitments to climate targets , for example. According to FactSet, a US financial data and software provider, the number of US companies in the S&P 500 index mentioning “ESG” on their earnings calls has declined sharply : from a peak of 155 in the fourth quarter 2021 to just 29 two years later. This trend towards playing down a company’s ESG efforts, from fear of greater scrutiny or of accusations of empty claims, even has a name: “greenhushing”.

Test yourself

This is the fourth in a series of monthly business school-style teaching case studies devoted to the responsible business dilemmas faced by organisations. Read the piece and FT articles suggested at the end before considering the questions raised.

About the authors: Gabriela Salinas is an adjunct professor of marketing at IE University; Jeeva Somasundaram is an assistant professor of decision sciences in operations and technology at IE University.

The series forms part of a wider collection of FT ‘instant teaching case studies ’, featured across our Business Education publications, that explore management challenges.

The change in approach is not limited to regulatory compliance and corporate reporting; it also affects consumer communications. While Jope believed that brands sold more when “guided by a purpose”, Schumacher argues that “we don’t want to force fit [purpose] on brands unnecessarily”.

His more nuanced view aligns with evidence that consumers’ responses to the sustainability and purpose communication attached to brand names depend on two key variables: the type of industry in which the brand operates; and the specific aspect of sustainability being communicated.

In terms of the sustainability message, research in the Journal of Business Ethics found consumers can be less interested when product functionality is key. Furthermore, a UK survey in 2022 found that about 15 per cent of consumers believed brands should support social causes, but nearly 60 per cent said they would rather see brand owners pay taxes and treat people fairly.

Among investors, too, “anti-purpose” and “anti-ESG” sentiment is growing. One (unnamed) leading bond fund manager even suggested to the FT that “ESG will be dead in five years”.

Media reports on the adverse impact of ESG controversies on investment are certainly now more frequent. For example, while Jope was still at the helm, the FT reported criticism of Unilever by influential fund manager Terry Smith for displaying sustainability credentials at the expense of managing the business.

Yet some executives feel under pressure to take a stand on environmental and social issues — in many cases believing they are morally obliged to do so or through a desire to improve their own reputations. This pressure may lead to a conflict with shareholders if sustainability becomes a promotional tool for managers, or for their personal social responsibility agenda, rather than creating business value .

Such opportunistic behaviours may lead to a perception that corporate sustainability policies are pursued only because of public image concerns.

Alison Taylor, at NYU Stern School of Business, recently described Unilever’s old materiality map — a visual representation of how companies assess which social and environmental factors matter most to them — to Sustainability magazine. She depicted it as an example of “baggy, vague, overambitious goals and self-aggrandising commitments that make little sense and falsely suggest a mayonnaise and soap company can solve intractable societal problems”.

In contrast, the “realism” approach of Schumacher is being promulgated as both more honest and more feasible. Former investment banker Alex Edmans, at London Business School, has coined the term “rational sustainability” to describe an approach that integrates financial principles into decision-making, and avoids using sustainability primarily for enhancing social image and reputation.

Such “rational sustainability” encompasses any business activity that creates long-term value — including product innovation, productivity enhancements, or corporate culture initiatives, regardless of whether they fall under the traditional ESG framework.

Similarly, Schumacher’s approach aims for fewer targets with greater impact, all while keeping financial objectives in sight.

Complex objectives, such as having a positive impact on the world, may be best achieved indirectly, as expounded by economist John Kay in his book, Obliquity . Schumacher’s “realistic sustainability” approach means focusing on long-term value creation, placing customers and investors to the fore. Saving the planet begins with meaningfully helping a company’s consumers and investors. Without their support, broader sustainability efforts risk failure.

Questions for discussion

Read: Unilever has ‘lost the plot’ by fixating on sustainability, says Terry Smith

Companies take step back from making climate target promises

The real impact of the ESG backlash

Unilever’s new chief says corporate purpose can be ‘unwelcome distraction ’

Unilever says new laxer environmental targets aim for ‘realism’

How should business executives incorporate ESG criteria in their commercial, investor, internal, and external communications? How can they strike a balance between purpose and profits?

How does purpose affect business and brand value? Under what circumstances or conditions can the impact of purpose be positive, neutral, or negative?

Are brands vehicles by which to drive social or environmental change? Is this the primary role of brands in the 21st century or do profits and clients’ needs come first?

Which categories or sectors might benefit most from strongly articulating and communicating a corporate purpose? Are there instances in which it might backfire?

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International Edition

Case Study Research Method in Psychology

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

Learn about our Editorial Process

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

On This Page:

Case studies are in-depth investigations of a person, group, event, or community. Typically, data is gathered from various sources using several methods (e.g., observations & interviews).

The case study research method originated in clinical medicine (the case history, i.e., the patient’s personal history). In psychology, case studies are often confined to the study of a particular individual.

The information is mainly biographical and relates to events in the individual’s past (i.e., retrospective), as well as to significant events that are currently occurring in his or her everyday life.

The case study is not a research method, but researchers select methods of data collection and analysis that will generate material suitable for case studies.

Freud (1909a, 1909b) conducted very detailed investigations into the private lives of his patients in an attempt to both understand and help them overcome their illnesses.

This makes it clear that the case study is a method that should only be used by a psychologist, therapist, or psychiatrist, i.e., someone with a professional qualification.

There is an ethical issue of competence. Only someone qualified to diagnose and treat a person can conduct a formal case study relating to atypical (i.e., abnormal) behavior or atypical development.

 Famous Case Studies

• Anna O – One of the most famous case studies, documenting psychoanalyst Josef Breuer’s treatment of “Anna O” (real name Bertha Pappenheim) for hysteria in the late 1800s using early psychoanalytic theory.
• Little Hans – A child psychoanalysis case study published by Sigmund Freud in 1909 analyzing his five-year-old patient Herbert Graf’s house phobia as related to the Oedipus complex.
• Bruce/Brenda – Gender identity case of the boy (Bruce) whose botched circumcision led psychologist John Money to advise gender reassignment and raise him as a girl (Brenda) in the 1960s.
• Genie Wiley – Linguistics/psychological development case of the victim of extreme isolation abuse who was studied in 1970s California for effects of early language deprivation on acquiring speech later in life.
• Phineas Gage – One of the most famous neuropsychology case studies analyzes personality changes in railroad worker Phineas Gage after an 1848 brain injury involving a tamping iron piercing his skull.

Clinical Case Studies

• Studying the effectiveness of psychotherapy approaches with an individual patient
• Assessing and treating mental illnesses like depression, anxiety disorders, PTSD
• Neuropsychological cases investigating brain injuries or disorders

Child Psychology Case Studies

• Studying psychological development from birth through adolescence
• Cases of learning disabilities, autism spectrum disorders, ADHD
• Effects of trauma, abuse, deprivation on development

Types of Case Studies

• Explanatory case studies : Used to explore causation in order to find underlying principles. Helpful for doing qualitative analysis to explain presumed causal links.
• Exploratory case studies : Used to explore situations where an intervention being evaluated has no clear set of outcomes. It helps define questions and hypotheses for future research.
• Descriptive case studies : Describe an intervention or phenomenon and the real-life context in which it occurred. It is helpful for illustrating certain topics within an evaluation.
• Multiple-case studies : Used to explore differences between cases and replicate findings across cases. Helpful for comparing and contrasting specific cases.
• Intrinsic : Used to gain a better understanding of a particular case. Helpful for capturing the complexity of a single case.
• Collective : Used to explore a general phenomenon using multiple case studies. Helpful for jointly studying a group of cases in order to inquire into the phenomenon.

Where Do You Find Data for a Case Study?

There are several places to find data for a case study. The key is to gather data from multiple sources to get a complete picture of the case and corroborate facts or findings through triangulation of evidence. Most of this information is likely qualitative (i.e., verbal description rather than measurement), but the psychologist might also collect numerical data.

1. Primary sources

• Interviews – Interviewing key people related to the case to get their perspectives and insights. The interview is an extremely effective procedure for obtaining information about an individual, and it may be used to collect comments from the person’s friends, parents, employer, workmates, and others who have a good knowledge of the person, as well as to obtain facts from the person him or herself.
• Observations – Observing behaviors, interactions, processes, etc., related to the case as they unfold in real-time.
• Documents & Records – Reviewing private documents, diaries, public records, correspondence, meeting minutes, etc., relevant to the case.

2. Secondary sources

• News/Media – News coverage of events related to the case study.
• Academic articles – Journal articles, dissertations etc. that discuss the case.
• Government reports – Official data and records related to the case context.
• Books/films – Books, documentaries or films discussing the case.

3. Archival records

Searching historical archives, museum collections and databases to find relevant documents, visual/audio records related to the case history and context.

Public archives like newspapers, organizational records, photographic collections could all include potentially relevant pieces of information to shed light on attitudes, cultural perspectives, common practices and historical contexts related to psychology.

4. Organizational records

Organizational records offer the advantage of often having large datasets collected over time that can reveal or confirm psychological insights.

Of course, privacy and ethical concerns regarding confidential data must be navigated carefully.

However, with proper protocols, organizational records can provide invaluable context and empirical depth to qualitative case studies exploring the intersection of psychology and organizations.

• Organizational/industrial psychology research : Organizational records like employee surveys, turnover/retention data, policies, incident reports etc. may provide insight into topics like job satisfaction, workplace culture and dynamics, leadership issues, employee behaviors etc.
• Clinical psychology : Therapists/hospitals may grant access to anonymized medical records to study aspects like assessments, diagnoses, treatment plans etc. This could shed light on clinical practices.
• School psychology : Studies could utilize anonymized student records like test scores, grades, disciplinary issues, and counseling referrals to study child development, learning barriers, effectiveness of support programs, and more.

How do I Write a Case Study in Psychology?

Follow specified case study guidelines provided by a journal or your psychology tutor. General components of clinical case studies include: background, symptoms, assessments, diagnosis, treatment, and outcomes. Interpreting the information means the researcher decides what to include or leave out. A good case study should always clarify which information is the factual description and which is an inference or the researcher’s opinion.

1. Introduction

• Provide background on the case context and why it is of interest, presenting background information like demographics, relevant history, and presenting problem.
• Compare briefly to similar published cases if applicable. Clearly state the focus/importance of the case.

2. Case Presentation

• Describe the presenting problem in detail, including symptoms, duration,and impact on daily life.
• Include client demographics like age and gender, information about social relationships, and mental health history.
• Describe all physical, emotional, and/or sensory symptoms reported by the client.
• Use patient quotes to describe the initial complaint verbatim. Follow with full-sentence summaries of relevant history details gathered, including key components that led to a working diagnosis.
• Summarize clinical exam results, namely orthopedic/neurological tests, imaging, lab tests, etc. Note actual results rather than subjective conclusions. Provide images if clearly reproducible/anonymized.
• Clearly state the working diagnosis or clinical impression before transitioning to management.

3. Management and Outcome

• Indicate the total duration of care and number of treatments given over what timeframe. Use specific names/descriptions for any therapies/interventions applied.
• Present the results of the intervention,including any quantitative or qualitative data collected.
• For outcomes, utilize visual analog scales for pain, medication usage logs, etc., if possible. Include patient self-reports of improvement/worsening of symptoms. Note the reason for discharge/end of care.

4. Discussion

• Analyze the case, exploring contributing factors, limitations of the study, and connections to existing research.
• Analyze the effectiveness of the intervention,considering factors like participant adherence, limitations of the study, and potential alternative explanations for the results.
• Identify any questions raised in the case analysis and relate insights to established theories and current research if applicable. Avoid definitive claims about physiological explanations.
• Offer clinical implications, and suggest future research directions.

5. Additional Items

• Thank specific assistants for writing support only. No patient acknowledgments.
• References should directly support any key claims or quotes included.
• Use tables/figures/images only if substantially informative. Include permissions and legends/explanatory notes.
• Provides detailed (rich qualitative) information.
• Provides insight for further research.
• Permitting investigation of otherwise impractical (or unethical) situations.

Case studies allow a researcher to investigate a topic in far more detail than might be possible if they were trying to deal with a large number of research participants (nomothetic approach) with the aim of ‘averaging’.

Because of their in-depth, multi-sided approach, case studies often shed light on aspects of human thinking and behavior that would be unethical or impractical to study in other ways.

Research that only looks into the measurable aspects of human behavior is not likely to give us insights into the subjective dimension of experience, which is important to psychoanalytic and humanistic psychologists.

Case studies are often used in exploratory research. They can help us generate new ideas (that might be tested by other methods). They are an important way of illustrating theories and can help show how different aspects of a person’s life are related to each other.

The method is, therefore, important for psychologists who adopt a holistic point of view (i.e., humanistic psychologists ).

Limitations

• Lacking scientific rigor and providing little basis for generalization of results to the wider population.
• Researchers’ own subjective feelings may influence the case study (researcher bias).
• Difficult to replicate.
• Time-consuming and expensive.
• The volume of data, together with the time restrictions in place, impacted the depth of analysis that was possible within the available resources.

Because a case study deals with only one person/event/group, we can never be sure if the case study investigated is representative of the wider body of “similar” instances. This means the conclusions drawn from a particular case may not be transferable to other settings.

Because case studies are based on the analysis of qualitative (i.e., descriptive) data , a lot depends on the psychologist’s interpretation of the information she has acquired.

This means that there is a lot of scope for Anna O , and it could be that the subjective opinions of the psychologist intrude in the assessment of what the data means.

For example, Freud has been criticized for producing case studies in which the information was sometimes distorted to fit particular behavioral theories (e.g., Little Hans ).

This is also true of Money’s interpretation of the Bruce/Brenda case study (Diamond, 1997) when he ignored evidence that went against his theory.

Breuer, J., & Freud, S. (1895).  Studies on hysteria . Standard Edition 2: London.

Curtiss, S. (1981). Genie: The case of a modern wild child .

Diamond, M., & Sigmundson, K. (1997). Sex Reassignment at Birth: Long-term Review and Clinical Implications. Archives of Pediatrics & Adolescent Medicine , 151(3), 298-304

Freud, S. (1909a). Analysis of a phobia of a five year old boy. In The Pelican Freud Library (1977), Vol 8, Case Histories 1, pages 169-306

Freud, S. (1909b). Bemerkungen über einen Fall von Zwangsneurose (Der “Rattenmann”). Jb. psychoanal. psychopathol. Forsch ., I, p. 357-421; GW, VII, p. 379-463; Notes upon a case of obsessional neurosis, SE , 10: 151-318.

Harlow J. M. (1848). Passage of an iron rod through the head.  Boston Medical and Surgical Journal, 39 , 389–393.

Harlow, J. M. (1868).  Recovery from the Passage of an Iron Bar through the Head .  Publications of the Massachusetts Medical Society. 2  (3), 327-347.

Money, J., & Ehrhardt, A. A. (1972).  Man & Woman, Boy & Girl : The Differentiation and Dimorphism of Gender Identity from Conception to Maturity. Baltimore, Maryland: Johns Hopkins University Press.

Money, J., & Tucker, P. (1975). Sexual signatures: On being a man or a woman.

Further Information

• Case Study Approach
• Case Study Method
• Enhancing the Quality of Case Studies in Health Services Research
• “We do things together” A case study of “couplehood” in dementia
• Using mixed methods for evaluating an integrative approach to cancer care: a case study

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AI on Trial: Legal Models Hallucinate in 1 out of 6 Queries

A new study reveals the need for benchmarking and public evaluations of AI tools in law.

Artificial intelligence (AI) tools are rapidly transforming the practice of law. Nearly  three quarters of lawyers plan on using generative AI for their work, from sifting through mountains of case law to drafting contracts to reviewing documents to writing legal memoranda. But are these tools reliable enough for real-world use?

Large language models have a documented tendency to “hallucinate,” or make up false information. In one highly-publicized case, a New York lawyer  faced sanctions for citing ChatGPT-invented fictional cases in a legal brief;  many similar cases have since been reported. And our  previous study of general-purpose chatbots found that they hallucinated between 58% and 82% of the time on legal queries, highlighting the risks of incorporating AI into legal practice. In his  2023 annual report on the judiciary , Chief Justice Roberts took note and warned lawyers of hallucinations. 

Across all areas of industry, retrieval-augmented generation (RAG) is seen and promoted as the solution for reducing hallucinations in domain-specific contexts. Relying on RAG, leading legal research services have released AI-powered legal research products that they claim  “avoid” hallucinations and guarantee  “hallucination-free” legal citations. RAG systems promise to deliver more accurate and trustworthy legal information by integrating a language model with a database of legal documents. Yet providers have not provided hard evidence for such claims or even precisely defined “hallucination,” making it difficult to assess their real-world reliability.

AI-Driven Legal Research Tools Still Hallucinate

In a new preprint study by  Stanford RegLab and  HAI researchers, we put the claims of two providers, LexisNexis and Thomson Reuters (the parent company of Westlaw), to the test. We show that their tools do reduce errors compared to general-purpose AI models like GPT-4. That is a substantial improvement and we document instances where these tools can spot mistaken premises. But even these bespoke legal AI tools still hallucinate an alarming amount of the time: these systems produced incorrect information more than 17% of the time—one in every six queries.

Read the full study, Hallucination-Free? Assessing the Reliability of Leading AI Legal Research Tools

To conduct our study, we manually constructed a pre-registered dataset of over 200 open-ended legal queries, which we designed to probe various aspects of these systems’ performance.

Broadly, we investigated (1) general research questions (questions about doctrine, case holdings, or the bar exam); (2) jurisdiction or time-specific questions (questions about circuit splits and recent changes in the law); (3) false premise questions (questions that mimic a user having a mistaken understanding of the law); and (4) factual recall questions (questions about simple, objective facts that require no legal interpretation).

Figure 1: Comparison of hallucinated (red) and incomplete (yellow) answers across generative legal research tools.

These systems can hallucinate in one of two ways. First, a response from an AI tool might just be  incorrect —it describes the law incorrectly or makes a factual error. Second, a response might be  misgrounded —the AI tool describes the law correctly, but cites a source which does not in fact support its claims.

Given the critical importance of authoritative sources in legal research and writing, the second type of hallucination may be even more pernicious than the outright invention of legal cases. A citation might be “hallucination-free” in the narrowest sense that the citation  exists , but that is not the only thing that matters. The core promise of legal AI is that it can streamline the time-consuming process of identifying relevant legal sources. If a tool provides sources that  seem authoritative but are in reality irrelevant or contradictory, users could be misled. They may place undue trust in the tool's output, potentially leading to erroneous legal judgments and conclusions.

Figure 2:  Left: Example of a hallucinated response by Thomson Reuters’s Ask Practical Law AI. The system fails to correct the user's mistaken premise—in reality, Justice Ginsburg joined the Court's landmark decision legalizing same-sex marriage—and instead provides additional false information about the case. Right: Example of a hallucinated response by LexisNexis’s Lexis+ AI.  Casey and its undue burden standard were overruled by the Supreme Court in  Dobbs v. Jackson Women's Health Organization , 597 U.S. 215 (2022); the correct answer is rational basis review.

RAG Is Not a Panacea

Figure 3: An overview of the retrieval-augmentation generation (RAG) process. Given a user query (left), the typical process consists of two steps: (1) retrieval (middle), where the query is embedded with natural language processing and a retrieval system takes embeddings and retrieves the relevant documents (e.g., Supreme Court cases); and (2) generation (right), where the retrieved texts are fed to the language model to generate the response to the user query. Any of the subsidiary steps may introduce error and hallucinations into the generated response. (Icons are courtesy of FlatIcon.)

Under the hood, these new legal AI tools use retrieval-augmented generation (RAG) to produce their results, a method that many tout as a potential solution to the hallucination problem. In theory, RAG allows a system to first  retrieve the relevant source material and then use it to  generate the correct response. In practice, however, we show that even RAG systems are not hallucination-free. 

We identify several challenges that are particularly unique to RAG-based legal AI systems, causing hallucinations. 

First, legal retrieval is hard. As any lawyer knows, finding the appropriate (or best) authority can be no easy task. Unlike other domains, the law is not entirely composed of verifiable  facts —instead, law is built up over time by judges writing  opinions . This makes identifying the set of documents that definitively answer a query difficult, and sometimes hallucinations occur for the simple reason that the system’s retrieval mechanism fails.

Second, even when retrieval occurs, the document that is retrieved can be an inapplicable authority. In the American legal system, rules and precedents differ across jurisdictions and time periods; documents that might be relevant on their face due to semantic similarity to a query may actually be inapposite for idiosyncratic reasons that are unique to the law. Thus, we also observe hallucinations occurring when these RAG systems fail to identify the truly binding authority. This is particularly problematic as areas where the law is in flux is precisely where legal research matters the most. One system, for instance, incorrectly recited the “undue burden” standard for abortion restrictions as good law, which was overturned in  Dobbs (see Figure 2). 

Third, sycophancy—the tendency of AI to agree with the user's incorrect assumptions—also poses unique risks in legal settings. One system, for instance, naively agreed with the question’s premise that Justice Ginsburg dissented in  Obergefell , the case establishing a right to same-sex marriage, and answered that she did so based on her views on international copyright. (Justice Ginsburg did not dissent in  Obergefell and, no, the case had nothing to do with copyright.) Notwithstanding that answer, here there are optimistic results. Our tests showed that both systems generally navigated queries based on false premises effectively. But when these systems do agree with erroneous user assertions, the implications can be severe—particularly for those hoping to use these tools to increase access to justice among  pro se and under-resourced litigants.

Responsible Integration of AI Into Law Requires Transparency

Ultimately, our results highlight the need for rigorous and transparent benchmarking of legal AI tools. Unlike other domains, the use of AI in law remains alarmingly opaque: the tools we study provide no systematic access, publish few details about their models, and report no evaluation results at all.

This opacity makes it exceedingly challenging for lawyers to procure and acquire AI products. The big law firm  Paul Weiss spent nearly a year and a half testing a product, and did not develop “hard metrics” because checking the AI system was so involved that it “makes any efficiency gains difficult to measure.” The absence of rigorous evaluation metrics makes responsible adoption difficult, especially for practitioners that are less resourced than Paul Weiss. 

The lack of transparency also threatens lawyers’ ability to comply with ethical and professional responsibility requirements. The bar associations of  California ,  New York , and  Florida have all recently released guidance on lawyers’ duty of supervision over work products created with AI tools. And as of May 2024,  more than 25 federal judges have issued standing orders instructing attorneys to disclose or monitor the use of AI in their courtrooms.

Without access to evaluations of the specific tools and transparency around their design, lawyers may find it impossible to comply with these responsibilities. Alternatively, given the high rate of hallucinations, lawyers may find themselves having to verify each and every proposition and citation provided by these tools, undercutting the stated efficiency gains that legal AI tools are supposed to provide.

Our study is meant in no way to single out LexisNexis and Thomson Reuters. Their products are far from the only legal AI tools that stand in need of transparency—a slew of startups offer similar products and have  made   similar   claims , but they are available on even more restricted bases, making it even more difficult to assess how they function. 

Based on what we know, legal hallucinations have not been solved and the legal profession should turn to public benchmarking and rigorous evaluations of AI tools. 

The authors of this study chose to evaluate “Ask Practical Law AI” because, despite several requests, they were not given access to Thomson Reuters’ other products at the time of the study. The authors look forward to evaluating more tools, but underscore that it should not be incumbent on academic researchers alone to provide transparency and empirical evidence on the reliability of marketed products. 

Paper authors: Varun Magesh is a research fellow at Stanford RegLab. Faiz Surani is a research fellow at Stanford RegLab. Matthew Dahl is a joint JD/PhD student in political science at Yale University and graduate student affiliate of Stanford RegLab. Mirac Suzgun is a joint JD/PhD student in computer science at Stanford University and a graduate student fellow at Stanford RegLab. Christopher D. Manning is Thomas M. Siebel Professor of Machine Learning, Professor of Linguistics and Computer Science, and Senior Fellow at HAI. Daniel E. Ho is the William Benjamin Scott and Luna M. Scott Professor of Law, Professor of Political Science, Professor of Computer Science (by courtesy), Senior Fellow at HAI, Senior Fellow at SIEPR, and Director of the RegLab at Stanford University. 

More News Topics

• Cases in Medical Ethics: Student-Led Discussions
• Markkula Center for Applied Ethics
• Focus Areas
• Bioethics Resources

Cases in Medical Ethics

Student-led discussions.

A selection of medical ethics cases designed to help determine whether medicine is the correct calling for pre-medical students.

I was a Hackworth Fellow for the Markkula Center for Applied Ethics at Santa Clara University. I was also a pre-medical student, and am currently attending the Loyola University Chicago Stritch School of Medicine. During my senior year at Santa Clara, I led discussions on medical ethics with students interested in medicine. The purpose of these discussions was two-fold. First, they were created to help bring current ethical issues onto our campus. Second, they were intended to help students who were interested in a career in the health sciences determine whether or not medicine is their correct calling. Most of the discussions followed a simple format. One to two cases were formulated for the students to read. Then I presented the students with various questions related to some of the ethical issues contained in the situations described. The following cases are the ones that I presented to the groups. Each case also has a short history and summary of the ethical issues being reviewed. The questions I asked of the students are included as well. These cases and questions are public domain, and can be re-used or modified for educational purposes. I hope that you find them useful, and that they spawn the same thoughtful enjoyment in you as they did in me.

Note: The cases were not based on specific events. However, it is possible that they share similarities with actual events. These similarities were not intended.

Autonomy essentially means "self rule," and it is a patient's most basic right. As such, it is a health care worker's responsibility to respect the autonomy of her patients. However, at times this can be difficult because it can conflict with the paternalistic attitude of many health care professionals. The following two cases address patient autonomy. The first involves the rights of an individual to decide her own fate, even against her physicians' judgments. The second case involves the rights of a parent to care for her child in the manner that she sees fit.

A woman enters the emergency room with stomach pain. She undergoes a CT scan and is diagnosed with an abdominal aortic aneurysm, a weakening in the wall of the aorta which causes it to stretch and bulge (this is very similar to what led to John Ritter's death). The physicians inform her that the only way to fix the problem is surgically, and that the chances of survival are about 50/50. They also inform her that time is of the essence, and that should the aneurysm burst, she would be dead in a few short minutes. The woman is an erotic dancer; she worries that the surgery will leave a scar that will negatively affect her work; therefore, she refuses any surgical treatment. Even after much pressuring from the physicians, she adamantly refuses surgery. Feeling that the woman is not in her correct state of mind and knowing that time is of the essence, the surgeons decide to perform the procedure without consent. They anesthetize her and surgically repair the aneurysm. She survives, and sues the hospital for millions of dollars. Questions for Case 1:

Do you believe that the physician's actions can be justified in any way?

Is there anything else that they could have done?

Is it ever right to take away someone's autonomy? (Would a court order make the physicians' decisions ethical?)

What would you do if you were one of the health care workers?

You are a general practitioner and a mother comes into your office with her child who is complaining of flu-like symptoms. Upon entering the room, you ask the boy to remove his shirt and you notice a pattern of very distinct bruises on the boy's torso. You ask the mother where the bruises came from, and she tells you that they are from a procedure she performed on him known as "cao gio," which is also known as "coining." The procedure involves rubbing warm oils or gels on a person's skin with a coin or other flat metal object. The mother explains that cao gio is used to raise out bad blood, and improve circulation and healing. When you touch the boy's back with your stethoscope, he winces in pain from the bruises. You debate whether or not you should call Child Protective Services and report the mother.

Questions for Case 2:

Should we completely discount this treatment as useless, or could there be something gained from it?

When should a physician step in to stop a cultural practice? (If someone answers "when it harms the child" remind that person that there is some pain in many of our medical procedures, for example, having one's tonsils removed)

Should the physician be concerned about alienating the mother and other people of her ethnicity from modern medicine?

Do you think that the physician should report the mother?

Autonomy Part 2 Maintenance of patient autonomy is one of the major ethical focuses of physicians. Therefore, a second discussion was also held that focused primarily on patient autonomy. This discussion also took a superficial look at euthanasia. For this discussion, a 58 minute video, Dax's Case (produced by Unicorn Media, for Concern for Dying ; produced by Donald Pasquella, Keith Burton ; directed by Donald Pasquella New York : Filmmakers Library, c1984) was used. The video tells the story of Dax Cowart, a man who was severely burned by an accidental propane explosion. The burns disabled Dax, and the physicians forced treatment on him. Though he survived the treatment, he still argues that he should have been allowed to refuse it so that he could die. The video is very useful; however, the videos of Dax's burn treatments are very graphic and the video should be reviewed before it is shown to a group of students.

In the video, one of the physicians says that burn patients are incompetent to make decisions when they first enter the hospital because they are in such a great deal of pain. However, patients such as Dax can be in a great deal of pain for a very long time. In such cases, what should be done to determine competence, and when should this be done?

Do you think the fact that Dax could not see a future for himself should have been taken into account when determining his competency? Could this have clouded his judgment? (He thought that he would end up on the street corner selling pencils)

Do you think that the fact that Dax was going to recover, and had the possibility of living a happy life, made not treating Dax like suicide… or murder? What if he did not have this possibility?

After his recovery, Dax attempted suicide. Should the physicians have let him die? Is it ever correct for a doctor to allow a patient to kill himself?

Do you ever think that it is correct for a physician to break a competent patient's autonomy? If so, is this one of those cases?

Do you think that in this case, that the ends justified the means?

The word "euthanasia" draws its roots from Greek meaning "good death." As it is used in this discussion, it means "the act of ending the life of a person suffering from either a terminal illness, or an incurable disease." The AMA is against physicians assisting in euthanasia. There is currently only one state in the US that allows for euthanasia, and that is Oregon, where in 1997, the "Death With Dignity Act" went into effect. Euthanasia advocates stress that it should be allowed as an extension of a person's autonomy. Those who are against euthanasia often say that it can lead to the devaluation of human life, and to a slippery slope in which the old and disabled will be killed on the whims of healthy people. We examined one case and the Oregon law to view the ethics of euthanasia.

Case One: A woman was diagnosed with motor neurone disease (the same disease that Stephen Hawking has) 5 years ago. This is a condition that destroys motor nerves, making control of movement impossible, while the mind is virtually unaffected. People with motor neurone disease normally die within 4 years of diagnosis from suffocation due to the inability of the inspiratory muscles to contract. The woman's condition has steadily declined. She is not expected to live through the month, and is worried about the pain that she will face in her final hours. She asks her doctor to give her diamorphine for pain if she begins to suffocate or choke. This will lessen her pain, but it will also hasten her death. About a week later, she falls very ill, and is having trouble breathing.

Questions for Case 1:

Does she have a right to make this choice, especially in view of the fact that she will be dead in a short while (say six hours)? Is this choice an extension of her autonomy?

Is the short amount of time she has to live ethically relevant? Is there an ethical difference between her dying in 6 hours and dying in a week? What about a year, and how do you draw this distinction?

Is the right for a patient's self-determination powerful enough to create obligations on the part of others to aid her so that she can exercise her rights? She clearly cannot kill herself. She can't move, but should someone be FORCED to help her, or to find someone to help her?

Should the money used to care for this woman be taken into account when she is being helped? Do you think that legalizing euthanasia could create conflicts of interest for the patient/ or the doctor? Will people feel that they need to end their lives earlier to save money?

Ask each student: If you were the physician, what would you do? Note: if you would pass her off to another doctor knowing he or she would do it, does this free you from you ethical obligations?

Oregon's Death With Dignity Act: We discussed the following questions pertaining to the Death With Diginity Act.

Death With Dignity Questions:

Look at the requirements for the request. Do you see any problems with them? (The woman from case 1 would not qualify.)

Why would they put in these guidelines? Should they be there, if they keep a competent person like the woman above from living her autonomy? (Is it to protect the doctors so they will not have to GIVE the medication?)

Is there a moral difference between prescribing the drug and actually giving it to the patient? If not, why put in the rules?

Why do you think they wouldn't let a person who is terminally ill and in pain with possibly more than 6 months receive assistance in dying? Say someone is diagnosed with HIV?

Does the justification of euthanasia necessarily justify the assisted suicide of a healthy person?

Do you think a weakness of this law is the probability of patients being influenced by family members? (For example, for financial or other reasons?) Note: Approximately 60% of Oregonians in 2000 said (before they died) that they used the prescription at least in some part due to fear of being a burden on their family.

The AMA says that euthanasia is fundamentally incompatible with the physician's role as healer. What do you think about this statement? Why should a physician have to be the one who does this?

Assisted Reproduction:

This is a difficult subject because it involves reproductive issues. In our culture, reproductive liberty, the freedom to decide when and where to conceive a child is highly protected, and this can make these cases much more difficult.

Case 1: There are two types of surrogacy. One type involves a surrogate mother who uses her own egg and carries the baby for someone else. The other type is a "gestational surrogacy" in which the mother has no genetic tie to the child she carries. In the case presented, a gestational surrogate is used.

A woman, after a bout with uterine cancer had a hysterectomy (surgical removal of the uterus). Before, its removal, however, she had several eggs removed for possible fertilization in the future. Now married, the woman wishes to have a child with her husband. Obviously she cannot bear the child herself, so the couple utilizes a company to find a surrogate mother for them. The husband's sperm is used to fertilize one of the wife's eggs, and is implanted in the surrogate mother. The couple pays all of the woman's pregnancy-related expenses and an extra $18,000 as compensation for her surrogacy. After all expenses are taken into account the couple pays the woman approximately $31,000 and the agency approximately $5,000. Though the surrogate passed stringent mental testing to ensure she was competent to carry another couple's child, after carrying the pregnancy to term, the surrogate says that she has become too attached to "her" child to give it up to the couple. A legal battle ensues.

In the United States it is illegal to pay a person for non-replenishable organs. The fear is that money will influence the poor to harm their bodies for the benefit of the rich. Do you see a parallel between this case and this law? Can allowing surrogate mothers to be paid for their troubles allow poorer women to be oppressed?

Does paying the surrogate harm her and/or the child's dignity?

Is it selfish/conceited for this couple to want children of their own genetic make-up? If yes, does this change if you can "easily" have a child? (Note: Over 100,000 children in the U.S. are waiting to be adopted. However, most are older, have several siblings, or have special needs.)

On their website, the AMA says "that surrogacy contracts [when the surrogate uses her own egg], while permissible, should grant the birth mother the right to void the contract within a reasonable period of time after the birth of the child. If the contract is voided, custody of the child should be determined according to the child's best interests." Do you see any problems with this? (What's a reasonable time? In a way can you steal the surrogate's child?)

One of the main arguments against the use of surrogate mothers is that carrying and giving birth to a child is such an emotional event that it is impossible to determine if the surrogate will be able to give up the child. Though adults enter into the contract, the child could ultimately suffer if a long custody battle ensues (as it could in states where surrogacy contracts hold no legal value, such as Virginia). With the possibility of such battles, do you think it is acceptable for parents to use a surrogate mother?

Do you think that if the surrogate is awarded the baby, this could cause emotional harm to the child?

Who do you think should receive the child, and why?

A married couple wishes to have a child; however, the 32 year old mother knows that she is a carrier for Huntington's disease (HD). HD is a genetic disorder that begins showing signs at anywhere from 35-45 years of age. Its symptoms begin with slow loss of muscle control and end in loss of speech, large muscle spasms, disorientation and emotional outbursts. After 15-20 years of symptoms HD ends in death. HD is a dominant disorder which means that her child will have a 50% chance of contracting the disorder. Feeling that risking their baby's health would be irresponsible, the couple decides to use in vitro fertilization to fertilize several of the wife's eggs. Several eggs are harvested, and using special technology, only eggs that do not have the defective gene are kept to be fertilized. The physician then fertilizes a single egg, and transfers the embryo to the mother. Approximately 9 months later, the couple gives birth to a boy who does not carry the gene for the disorder.

Is this a case of eugenics? "Eugenics" is defined as "the hereditary improvement of the human race controlled by selective breeding" (dictionary.com)

Would it be acceptable for the parents to select for sex as well, or should they only select an embryo that does not have HD? How would this be different?

Is it ethical for this couple to have a baby when the mother could begin showings signs of HD when the baby is just a few years old?

With this technology possible, would it be ethical for this couple to have a child without genetically ensuring it would not have the disease? What if we did not have this technology, would it be ethical for a known carrier to have a child? (If not, how far should this carry? a carrier for cystic fibrosis ( which is recessive)? )

Weighing everything we have discussed, do you believe the couple acted ethically?

Response To Bio-Terrorism

The possibility of terrorists using biological weapons on the citizens of the United States has been a major topic in the press for the last several years. Smallpox has been speculated to be the perfect biological terror agent because of the potency of the virus, and because of the lack of herd immunity present in the US population. The following case presents a possible way in which the virus could be released in the population and a possible response. The questions following the case involve the ethics surrounding the government's response.

Smallpox Facts:

Smallpox initially has flu-like symptoms, which are recognizable 7-19 days after exposure. After 2-4 days of flu-like symptoms, the fever begins to decrease, and pox will form.

An infected person is contagious one day before the characteristic pox appear.

Approximately 30-50% of unvaccinated people exposed to smallpox will contract the disease.

The mortality rate for smallpox was approximately 20-40%.

The vaccine that was used was approximately 90% effective.

It is possible that if terrorists were to use the smallpox virus, that they would genetically modify it. If this were the case, then the vaccine may not prevent all of the disease symptoms for those vaccinated.

Facts gathered from: http://www.vbs.admin.ch/ls/e/current/fact_sheet/pocken/

Date: June 22, 2005. A 27-year-old man is brought into a New York City emergency room with a 101-degree fever, and what he believes is chickenpox (Varicella). After a brief examination, the 35-year-old physician is puzzled because the pox do not appear to be typical of the varicella-zoster virus. Worried, he calls in another physician for her opinion. She takes one look at the patient, determines he has small pox, and immediately orders him to be quarantined. She notifies the Centers for Disease Control and Prevention (CDC) and asks them what should be done. While doing background on the patient, he tells the physicians that he is a flight attendant and that he has flown to Orlando, FL, Los Angeles, CA, Chicago, IL, and Seattle, WA in the past few weeks while working. Though he is given excellent treatment, and had been in perfect health a few days earlier, the patient dies 7 hours after admittance to the hospital.

The CDC decides that mandatory small pox vaccines will be administered to all workers in the NYC hospital, and to all patients who were in the ER. His co-workers are all given mandatory vaccines as well, as are all people living in his apartment complex. They also ship stored quantities of the vaccine to all of the cities where the man had flown to for work. The vaccines are offered to citizens of these cities. Finally, all people, along with their families who had been on the man's flights in the weeks preceding the appearance of the disease are forced to receive the vaccine.

Questions: Note: The flight attendant was most likely given small pox by a bio terrorist who flew on his plane sometime during the past week/week and a half. The terrorist would have been contagious but would not have shown symptoms. Virtually every person the man came into contact with would have gotten the virus.

Is it ethical for the CDC to force people to get the vaccine?

An LA woman on the flight is religiously opposed to vaccines. Under California law she can normally refuse vaccines on religious or personal grounds. However, the government says she must receive the vaccine or face mandatory quarantine. What do you think of this?

Do you think that for more common diseases, for example measles, that it is ethical for the state to allow people to refuse vaccines (even for religious grounds)? What if their refusal can harm others who cannot have the vaccine, such as people who are immunocompromised like AIDS patients?

Is it ethical for someone to refuse the vaccine?

You had driven down to Los Angeles 5 days ago to visit a friend for the weekend. While in town, you visited many tourist attractions. You are worried and you try to get the vaccine, but are denied it because of limited resources. What do you think of this?

Citizens begin calling for the mandatory quarantining of people directly exposed to the victim, i.e those living in his apartment complex, those working in the ER, those who flew on the plane in the prior week. What do you think of this?

The smallpox vaccine, like many other vaccines (example: oral polio vaccine) can actually transmit the virus to others. In light of this, is it ethical for people to get the vaccine? (Note: they are vaccinating those who may not want to be vaccinated)

Today, should health care workers be allowed/forced to get the smallpox vaccine? What about non-health care worker citizens?

• Open access
• Published: 24 May 2024

Integration of case-based learning and three-dimensional printing for tetralogy of fallot instruction in clinical medical undergraduates: a randomized controlled trial

• Jian Zhao 1   na1 ,
• Xin Gong 1   na1 ,
• Jian Ding 1 ,
• Kepin Xiong 2 ,
• Kangle Zhuang 3 ,
• Rui Huang 1 ,
• Shu Li 4 &
• Huachun Miao 1  

BMC Medical Education volume  24 , Article number:  571 ( 2024 ) Cite this article

Metrics details

Case-based learning (CBL) methods have gained prominence in medical education, proving especially effective for preclinical training in undergraduate medical education. Tetralogy of Fallot (TOF) is a congenital heart disease characterized by four malformations, presenting a challenge in medical education due to the complexity of its anatomical pathology. Three-dimensional printing (3DP), generating physical replicas from data, offers a valuable tool for illustrating intricate anatomical structures and spatial relationships in the classroom. This study explores the integration of 3DP with CBL teaching for clinical medical undergraduates.

Sixty senior clinical medical undergraduates were randomly assigned to the CBL group and the CBL-3DP group. Computed tomography imaging data from a typical TOF case were exported, processed, and utilized to create four TOF models with a color 3D printer. The CBL group employed CBL teaching methods, while the CBL-3DP group combined CBL with 3D-printed models. Post-class exams and questionnaires assessed the teaching effectiveness of both groups.

The CBL-3DP group exhibited improved performance in post-class examinations, particularly in pathological anatomy and TOF imaging data analysis ( P  < 0.05). Questionnaire responses from the CBL-3DP group indicated enhanced satisfaction with teaching mode, promotion of diagnostic skills, bolstering of self-assurance in managing TOF cases, and cultivation of critical thinking and clinical reasoning abilities ( P  < 0.05). These findings underscore the potential of 3D printed models to augment the effectiveness of CBL, aiding students in mastering instructional content and bolstering their interest and self-confidence in learning.

The fusion of CBL with 3D printing models is feasible and effective in TOF instruction to clinical medical undergraduates, and worthy of popularization and application in medical education, especially for courses involving intricate anatomical components.

Peer Review reports

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease(CHD) [ 1 ]. Characterized by four structural anomalies: ventricular septal defect (VSD), pulmonary stenosis (PS), right ventricular hypertrophy (RVH), and overriding aorta (OA), TOF is a focal point and challenge in medical education. Understanding anatomical spatial structures is pivotal for learning and mastering TOF [ 2 ]. Given the constraints of course duration, medical school educators aim to provide students with a comprehensive and intuitive understanding of the disease within a limited timeframe [ 3 ].

The case-based learning (CBL) teaching model incorporates a case-based instructional approach that emphasizes typical clinical cases as a guide in student-centered and teacher-facilitated group discussions [ 4 ]. The CBL instructional methods have garnered widespread attention in medical education as they are particularly appropriate for preclinical training in undergraduate medical education [ 5 , 6 ]. The collection of case data, including medical records and examination results, is essential for case construction [ 7 ]. The anatomical and hemodynamic consequences of TOF can be determined using ultrasonography, computed tomography (CT), and magnetic resonance imaging techniques. However, understanding the anatomical structures from imaging data is a slow and challenging psychological reconstruction process for undergraduate medical students [ 8 ]. Three-dimensional (3D) visualization is valuable for depicting anatomical structures [ 9 ]. 3D printing (3DP), which creates physical replicas based on data, facilitates the demonstration of complex anatomical structures and spatial relationships in the classroom [ 10 ].

During the classroom session, 3D-printed models offer a convenient means for hands-on demonstration and communication, similar to facing a patient, enhancing the efficiency and specificity of intra-team communication and discussion [ 11 ]. In this study, we printed TOF models based on case imaging data, integrated them into CBL teaching, and assessed the effectiveness of classroom instruction.

Research participants

The study employed a prospective, randomized controlled design which received approval from the institutional ethics committee. Senior undergraduate students majoring in clinical medicine at Wannan Medical College were recruited for participation based on predefined inclusion criteria. The researchers implemented recruitment according to the recruitment criteria by contacting the class leaders of the target classes they had previously taught. Notably, these students were in their third year of medical education, with anticipation of progressing to clinical courses in the fourth year, encompassing Internal Medicine, Surgery, Obstetrics, Gynecology, and Pediatrics. Inclusion criteria for participants encompassed the following: (1) proficient communication and comprehension abilities, (2) consistent attendance without absenteeism or truancy, (3) absence of failing grades in prior examinations, and (4) capability to conscientiously fulfill assigned learning tasks. Exclusion criteria were (1) absence from lectures, (2) failure to complete pre-and post-tests, and (3) inadequate completion of questionnaires. For their participation in the study, Students were provided access to the e-book “Localized Anatomy,” authored by the investigators, as an incentive for their participation. Voluntary and anonymous participation was emphasized, with participants retaining the right to withdraw from the study at any time without providing a reason.

The study was conducted between May 1st, 2023, and June 30, 2023, from recruitment to completion of data collection. Drawing upon insights gained from a previous analogous investigation which yielded an effect size of 0.95 [ 10 ]. Sample size was computed, guided by a statistical consultant, with the aim of 0.85 power value, predicated on an effect size of 0.8 and a margin of error set at 0.05. A minimum of 30 participants per group was calculated using G*Power software (latest ver. 3.1.9.7; Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany), resulting in the recruitment of a total of 60 undergraduate students. Each participant was assigned an identification number, with codes placed in boxes. Codes drawn from the boxes determined allocation to either the CBL group or the CBL-3DP group. Subsequently, participants were randomly assigned to either the CBL group, receiving instruction utilizing the CBL methodology, or the CBL-3DP group, which received instruction integrating both CBL and 3D Printed models.

Printing of TOF models

Figure  1 A shows the printing flowchart of the TOF models. A typical TOF case was collected from the Yijishan Hospital of Wannan Medical College. The CT angiography imaging data of the case was exported. Mimics Research 20.0 software (Mimics Innovation Suite version 20, Materialize, Belgium) was used for data processing. The cardiovascular module of the CT-Heart tool was employed to adjust the threshold range, independently obtain the cardiac chambers and vessels, post-process the chambers and vessels to generate a hollow blood pool, and merge it with the myocardial volume to construct a complete heart model. The file was imported into Magics 24.0 software (version 24.0; Materialize, Belgium) for correction using the Shell tool page. After repairs, the model entered the smoothing page, where tools such as triangular surface simplification, local smoothing, refinement and smoothing, subdivision of components, and mesh painting were utilized to achieve varying degrees of smoothness. Finally, optimized data were obtained and exported as stereolithography (STL) files. An experienced cardiothoracic surgeon validated the anatomical accuracy of the digital model.

The STL files were imported into a 3D printer (J401Pro; Sailner 3D Technology, China) for model printing. This printer can produce full-color medical models using different materials. The models were fabricated using two distinct materials: rigid and flexible. Both materials are suitable for the observational discussion of the teaching objectives outlined in our study. From the perspective of observing pathological changes in the TOF, there is no significant difference between the two materials.

Experimental flow chart of this study. A TOF model printing flow chart. B The instructional framework

Teaching implementation

Figure  1 B illustrates the instructional framework employed in this study. One week preceding the class session, all the students were tasked with a 30-minute self-study session, focusing on the theoretical content related to TOF as outlined in the Pediatrics and Surgery textbooks, along with a review of pertinent academic literature. Both groups received co-supervision from two basic medicine lecturers boasting over a decade of teaching experience, alongside a senior cardiothoracic surgeon. Teaching conditions remained consistent across groups, encompassing uniform assessment criteria and adherence to predefined teaching time frames, all conducted in a Project-Based Learning (PBL) classroom at Wannan Medical College. Additionally, a pre-course examination was administered to gauge students’ preparedness for self-study.

In adherence to the curriculum guidelines, the teaching objectives aimed to empower students to master TOF’s clinical manifestations, diagnostic modalities, and differential diagnoses, while acquainting them with treatment principles and surgical methodologies. Additionally, the objectives sought to cultivate students’ clinical reasoning abilities and problem-solving skills. the duration of instruction for the TOF theory session was standardized to 25 min. The didactic content was integrated with the TOF case study to construct a coherent pedagogical structure.

During the instructional session, both groups underwent teaching utilizing the CBL methodology. Clinical manifestations and case details of TOF cases were presented to stimulate students’ interest and curiosity. Subsequently, the theory of TOF, including its etiology, pathogenesis, pathologic anatomy, clinical manifestations, diagnostic methods, and therapeutic interventions, was briefly elucidated. Emphasis was then placed on the case, wherein selected typical TOF cases were explained, guiding students in analysis and discussion. Students were organized into four teams under the instructors’ supervision, fostering cooperative learning and communication, thereby deepening their understanding of the disease through continuous inquiry and exploration (Fig.  2 L). In the routinely equipped PBL classroom with standard heart models (Fig.  2 J, K), all students had prior exposure to human anatomy and were familiar with these models. Both groups were provided with four standard heart models for reference, while the CBL-3DP group received additional four 3D-printed models depicting TOF anomalies, enriching their learning experience (Fig.  2 D, G). After the lesson, summarization, and feedback sessions were conducted to consolidate group discussions’ outcomes, evaluate teaching effectiveness, and assess learning outcomes.

Heart models utilized in instructional sessions. A External perspective of 3D digital models. B, C Cross-sectional views following trans-septal sagittal dissection of the 3D digital model (PS: Pulmonary Stenosis; OA: Overriding Aorta; VSD: Ventricular Septal Defect; RVH: Right Ventricular Hypertrophy). D External depiction of rigid 3D printed model. E, F Sagittal sections of the rigid 3D printed model. G External portrayal of flexible 3D printed model. H, I Sagittal sections of the flexible 3D printed model. J, K The normal heart model employed in the instruction of the CBL group. L Ongoing classroom session

Teaching effectiveness assessment

Following the instructional session, participants from the two groups underwent a theoretical examination to assess their comprehension of the taught material. This assessment covered domains such as pathological anatomy, clinical manifestations, imaging data interpretation, diagnosis, and treatment relevant to TOF. Additionally, structured questionnaires were administered to evaluate the efficacy of the pedagogical approach employed. The questionnaire consisted of six questions designed to gauge participants’ understanding of the teaching content, enhancement of diagnostic skills, cultivation of critical thinking and clinical reasoning abilities, bolstering of confidence in managing TOF cases, satisfaction with the teaching mode, and satisfaction with the CBL methodology.

The questionnaire employed a 5-point Likert scale to gauge responses, with 5 indicating “strongly satisfied/agree,” 4 for “satisfied/agree,” 3 denoting “neutral,” 2 reflecting “dissatisfied/disagree,” and 1 indicating “strongly dissatisfied/disagree.” It comprised six questions, with the initial two probing participants’ knowledge acquisition, questions 3 and 4 exploring satisfaction regarding enhanced competence, and the final two assessing satisfaction with teaching methods and modes. Additionally, participants were encouraged to provide suggestions at the end of the questionnaire. To ensure the questionnaire’s validity, five esteemed lecturers in basic medical sciences with more than 10 years of experience verified its content and assessed its Content Validity Ratio and Content Validity Index to ensure alignment with the study’s objectives.

Statistical analysis

Statistical analyses were conducted utilizing GraphPad Prism 9.0 software. Aggregate score data for both groups were presented as mean ± standard deviation (x ± s). The gender comparisons were analyzed with the chi-square (χ2) test, while the other variables were compared using the Mann-Whitney U test. The threshold for determining statistical significance was set at P  < 0.05.

Three-dimensional printing models

After configuring the structural colors of each component (Fig.  2 A, B, C), we printed four color TOF models using both rigid and flexible materials, resulting in four life-sized TOF models. Two color TOF models were created using rigid materials (Fig.  2 D, E, F). These models, exhibiting resistance to deformation, and with a firm texture, smooth and glossy surface, and good transparency, allowing visibility of the internal structures, were deemed conducive to teaching and observation. We also fabricated two color TOF models using flexible materials (Fig.  2 G, H, I), characterized by soft texture, opacity, and deformability, allowing for easy manipulation and cutting. It has potential utility beyond observational purposes. It can serve as a valuable tool for simulating surgical interventions and may be employed to create tomographic anatomical specimens. In this study, both material models were suitable for observation in the classroom. The participants were able to discern the four pathological changes characteristic of TOF from surface examination or cross-sectional analysis.

Baseline characteristics of the students

In total, 60 students were included in this study. The CBL group comprised 30 students (14 males and 16 females), with an average age of (21.20 ± 0.76) years. The CBL-3DP group consisted of 30 students (17 males and 13 females) with an average age of 20.96 years. All the students completed the study procedures. There were no significant differences in age, sex ratio, or pre-class exam scores between the two groups ( P  > 0.05), indicating that the baseline scores between the two groups were comparable (Table  1 ).

Theoretical examination results

All students completed the research procedures as planned. The post-class theoretical examination encompassed assessment of pathological anatomy, clinical presentations, imaging data interpretation, diagnosis, and treatment pertinent to TOF. Notably, no statistically significant disparities were observed in the scores on clinical manifestations, diagnosis and treatment components between the cohorts, as delineated in Table  2 . Conversely, discernible distinctions were evident whereby the CBL-3DP group outperformed the CBL group notably in pathological anatomy, imaging data interpretation, and overall aggregate scores ( P  < 0.05).

Results of the questionnaires

All the 60 participants submitted the questionnaire. Comparing the CBL and CBL-3DP groups, the scores from the CBL-3DP group showed significant improvements in many areas. This included satisfaction with the teaching mode, promotion of diagnostic skills, bolstering of self-assurance in managing TOF cases, and cultivation of critical thinking and clinical reasoning abilities (Fig.  3 B, C, D, E). All of which improved significantly ( P  < 0.05 for the first aspects and P  < 0.01 for the rest). However, the two groups were not comparable ( P  > 0.05) in terms of understanding of the teaching content and Satisfaction with the CBL methodology (Fig.  3 A, F).

Upon completion of the questionnaires, participants were invited to proffer recommendations. Notably, in the CBL group, seven students expressed challenges in comprehending TOF and indicated a need for additional time for consolidation to enhance understanding. Conversely, within the CBL-3DP group, twelve students advocated for the augmentation of model repertoire and the expansion of disease-related data collection to bolster pedagogical efficacy across other didactic domains.

Five-point Likert scores of students’ attitudes in CBL ( n  = 30) and CBL-3DP ( n  = 30) groups. A Understanding of teaching content. B Promotion of diagnostic skills. C Cultivation of critical thinking and clinical reasoning abilities. D Bolstering of self-assurance in managing TOF cases. E Satisfaction with the teaching mode. F Satisfaction with the CBL methodology. ns No significant difference, * p  < 0.05, ** p  < 0.01, *** p  < 0.001

TOF presents a significant challenge in clinical practice, necessitating a comprehensive understanding for effective diagnosis and treatment [ 12 ]. Traditional teaching methods in medical schools have relied on conventional resources such as textbooks, 2D illustrations, cadaver dissections, and radiographic materials to impart knowledge about complex conditions like TOF [ 13 ]. However, the limitations of these methods in fully engaging students and bridging the gap between theoretical knowledge and practical application have prompted a need for innovative instructional approaches.

CBL has emerged as a valuable tool in medical education, offering students opportunities to engage with authentic clinical cases through group discussions and inquiry-based learning [ 14 ]. By actively involving students in problem-solving and decision-making processes, CBL facilitates the application of theoretical knowledge to real-world scenarios, thus better-preparing students for future clinical practice [ 15 ]. Our investigation revealed that both groups of students exhibited comparable levels of satisfaction with the CBL methodology, devoid of discernible disparities.

CHD presents a formidable challenge due to the intricate nature of anatomical anomalies, the diverse spectrum of conditions, and individual variations [ 16 ]. Utilizing 3D-printed physical models, derived from patient imaging data, can significantly enhance comprehension of complex anatomical structures [ 17 ]. These models have proven invaluable in guiding surgical planning, providing training for junior or inexperienced pediatric residents, and educating healthcare professionals and parents of patients [ 18 ]. Studies indicate that as much as 50% of pediatric surgical decisions can be influenced by the insights gained from 3D printed models [ 19 ]. By providing tangible, anatomically accurate models, 3D printing offers a unique opportunity for people to visualize complex structures and enhance their understanding of anatomical intricacies. Our study utilized full-color, to-scale 3D printed models to illustrate the structural abnormalities associated with TOF, thereby enriching classroom sessions and facilitating a deeper comprehension of the condition.

Comparative analysis between the CBL-3DP group and the CBL group revealed significant improvements in post-test performance, particularly in pathological anatomy and imaging data interpretation. Additionally, questionnaire responses indicated higher levels of satisfaction and confidence among students in the CBL-3DP group, highlighting the positive impact of incorporating 3D printed models into the learning environment, improving the effectiveness of CBL classroom instruction. Despite the merits, our study has limitations. Primarily, participants were exclusively drawn from the same grade level within a single college, possibly engendering bias owing to shared learning backgrounds. Future research could further strengthen these findings by expanding the sample size and including long-term follow-up to assess the retention of knowledge and skills. Additionally, the influence of the 3D models depicting a normal heart on the learning process and its potential to introduce bias into the results warrants consideration, highlighting a need for scrutiny in subsequent studies.

As medical science continues to advance, the need for effective teaching methods becomes increasingly paramount. Our study underscores the potential of combining active learning approaches like CBL with innovative technologies such as 3D printing to enhance teaching effectiveness, improve knowledge acquisition, and foster students’ confidence and enthusiasm in pursuing clinical careers. Moving forward, further research and integration of such methodologies are essential for meeting the evolving demands of medical education, especially in areas involving complex anatomical understanding.

Conclusions

Integrating 3D-printed models with the CBL method is feasible and effective in TOF instruction. The demonstrated success of this method warrants broad implementation in medical education, particularly for complex anatomical topics.

Data availability

All data supporting the conclusions of this research are available upon reasonable request from the corresponding author.

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Acknowledgements

We extend our sincere appreciation to the instructors and students whose invaluable participated in this study.

This paper received support from the Education Department of Anhui Province, China (Grant Numbers 2022jyxm1693, 2022jyxm1694, 2022xskc103, 2018jyxm1280).

Author information

Jian Zhao and Xin Gong are joint first authors.

Authors and Affiliations

Department of Human Anatomy, Wannan Medical College, No.22 West Wenchang Road, Wuhu, 241002, China

Jian Zhao, Xin Gong, Jian Ding, Rui Huang & Huachun Miao

Department of Cardio-Thoracic Surgery, Yijishan Hospital of Wannan Medical College, Wuhu, China

Kepin Xiong

Zhuhai Sailner 3D Technology Co., Ltd., Zhuhai, China

Kangle Zhuang

School of Basic Medical Sciences, Wannan Medical College, Wuhu, China

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Contributions

Jian Zhao and Huachun Miao designed the research. Jian Zhao, Xin Gong, Jian Ding, Kepin Xiong designed the tests and questionnaires. Kangle Zhuang processed the imaging data and printed the models. Xing Gong and Kepin Xiong implemented the teaching. Jian Zhao and Rui Huang collected the data and performed the statistical analysis. Jian Zhao and Huachun Miao prepared the manuscript. Shu Li and Huachun Miao revised the manuscript. Shu Li provided the Funding acquisition. All authors reviewed and approved the final manuscript.

Corresponding authors

Correspondence to Shu Li or Huachun Miao .

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This investigation received ethical approval from the Ethical Committee of School of Basic Medical Sciences, Wannan Medical College (ECBMSWMC2022-1-12). All methodologies adhered strictly to established protocols and guidelines. Written informed consent was obtained from the study participants to take part in the study.

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Written informed consent was obtained from the individuals for the publication of any potentially identifiable images or data included in this article.

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Zhao, J., Gong, X., Ding, J. et al. Integration of case-based learning and three-dimensional printing for tetralogy of fallot instruction in clinical medical undergraduates: a randomized controlled trial. BMC Med Educ 24 , 571 (2024). https://doi.org/10.1186/s12909-024-05583-z

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Received : 03 March 2024

Accepted : 21 May 2024

Published : 24 May 2024

DOI : https://doi.org/10.1186/s12909-024-05583-z

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2024 Gen Z and Millennial Survey: Living and working with purpose in a transforming world

The 13th edition of Deloitte’s Gen Z and Millennial Survey connected with nearly 23,000 respondents across 44 countries to track their experiences and expectations at work and in the world more broadly.

Gen Zs and millennials are cautiously optimistic about the economy and their personal finances, but uncertainty remains

Just under a third of Gen Zs and millennials believe the economic situation in their countries will improve over the next year, reflecting the most optimism respondents have shown about the economy since our 2020 study fielded just before the COVID-19 pandemic. This optimism is also reflected in Gen Zs’ and millennials’ outlook for their personal financial situations, although financial insecurity continues to plague these generations.

Three in 10 say they do not feel financially secure. And roughly six in 10 live paycheck to paycheck. The cost of living remains their top concern by a wide margin compared to their other leading concerns, which include climate change, unemployment, mental health, and crime/personal safety.

There is some uncertainty about the social and political outlook, with only about a quarter of respondents believing it will improve in their country over the next year.

Gen Zs and millennials think the following will improve in their countries in the year ahead

Nearly all gen zs and millennials want purpose-driven work, and they are not afraid to turn down work that doesn’t align with their values.

Having a sense of purpose is key to workplace satisfaction and well-being. And increasingly, these generations are willing to turn down assignments and employers based on their personal ethics or beliefs. Reasons for rejecting an employer or an assignment include factors such as having a negative environmental impact, or contributing to inequality through non inclusive practices, and more personal factors such as a lack of support for employees’ mental well-being and work/life balance.

Those who...

Climate action, environmental sustainability is everyone’s responsibility.

Environmental sustainability continues to be among Gen Zs’ and millennials’ top priorities. It is a personal concern that consistently weighs heavily on them, with roughly six in 10 Gen Zs and millennials saying they have felt worried or anxious about climate change in the last month.

The majority of them take action to minimize their impact on the environment. They feel governments should play a bigger role in pushing business to address climate change. And that business, in turn, could and should do more to enable consumers to make more sustainable purchasing decisions.

Protecting the environment is the societal challenge where respondents feel businesses have the most opportunity to drive change. Gen Zs and millennials are pushing business to act through their career decisions and consumer behaviors.

Percentage of Gen Zs and millennials who...

Genai at work, positive perceptions of genai increase with more hands-on experience, but so do workplace concerns.

Among both generations, frequent users of GenAI are more likely to believe the technology will have positive effects on their work and improve their work/life balance.

But, conversely, the more a respondent uses GenAI, the more likely they are to have some concerns as well, such as believing that GenAI will cause the elimination of jobs, make it harder for younger generations to enter the workforce, or that they’ll have to find job opportunities that are less vulnerable to automation.

In response to these types of concerns, both generations are thinking about how to adapt, with a focus on reskilling and GenAI training.

Respondents who say that GenAI in the workplace will...

Future of work, gen zs’ and millennials’ career and workplace expectations are evolving.

Many Gen Zs and millennials are choosing career paths based on environmental concerns, or which they believe will be less vulnerable to automation. And, once they do choose an employer, they push for change, particularly when it comes to workload, the services offered to clients, learning and development, DEI, wellness, social impact, and environmental efforts.

Work remains key to Gen Zs’ and, even more so to millennials’, sense of identity, with their jobs coming second only to friends and family. However, they are very focused on maintaining a positive work/life balance. And their strong preference for flexible work is driving greater demand for part-time jobs, job-sharing options, and models such as four-day work weeks for full-time employees.

Meanwhile, roughly a third of Gen Zs and millennials say they work for organizations who have recently implemented a return-to-office policy. These policies have yielded mixed results.

• Six in 10 Gen Zs (61%) and millennials (58%) believe they have the power to drive change within their organizations.
• Consistent with last year’s findings, work/life balance is the top consideration when Gen Zs and millennials are choosing an employer.
• Two-thirds of Gen Zs (64%) and millennials (66%) say they work for organizations who have recently implemented a return-to-office policy.

Mental health

As workplace factors contribute to stress levels, employers must stay focused on providing better workplace mental health.

Only about half of Gen Zs (51%) and millennials (56%) rate their mental health as good or extremely good. And while stress levels have improved slightly since last year, they remain high, with 40% of Gen Zs and 35% of millennials saying they feel stressed all or most of the time.

About a third of respondents say that their job and their work/life balance contribute a lot to their stress levels.

Financial concerns, and family welfare are major stressors, alongside job related factors such as long working hours and lack of recognition.

Many respondents believe that their employers are taking mental health seriously. But despite some positive changes, there is room for improvement when it comes to enabling people to feel comfortable speaking openly about mental health at work. Managers and senior leaders need to play an important role to remove stigma.

Percentage of respondents who say...

To learn more about the mental health findings, read the Mental Health Deep Dive .

Gen Zs and millennials have played a significant role in pushing the boundaries of what is expected from employers over the last decade, and they will continue to do so. Employers who listen and adjust their strategies will likely have a more satisfied, productive, and agile workforce who are better prepared to adapt to a transforming world.

Additional links

• Gen Z and Millennial Survey press release
• 2023 Gen Z and Millennial Survey
• Deloitte Insights article

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Persistent symptoms and clinical findings in adults with post-acute sequelae of COVID-19/post-COVID-19 syndrome in the second year after acute infection: population-based, nested case-control study

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Objective To assess risk factors for persistence vs improvement and to describe clinical characteristics and diagnostic evaluation of subjects with post-acute sequelae of COVID-19/post-COVID-19 syndrome (PCS) persisting for more than one year.

Design Nested population-based case-control study.

Setting Comprehensive outpatient assessment, including neurocognitive, cardiopulmonary exercise, and laboratory testing in four university health centres in southwestern Germany (2022).

Participants PCS cases aged 18 to 65 years with (n=982) and age and sex-matched controls without PCS (n=576) according to an earlier population-based questionnaire study (six to 12 months after acute infection, phase 1) consenting to provide follow-up information and to undergo clinical diagnostic assessment (phase 2, another 8.5 months [median] after phase 1).

Main outcome measures Relative frequencies of symptoms and health problems and distribution of symptom scores and diagnostic test results between persistent cases and controls. Additional analysis included predictors of changing case or control status over time with adjustments for potentially confounding variables.

Results At the time of clinical examination (phase 2), 67.6% of the initial cases (phase 1) remained cases, whereas 78.5% of the controls continued to report no health problems related to PCS. In adjusted analyses, predictors of improvement among cases were mild acute index infection, previous full-time employment, educational status, and no specialist consultation and not attending a rehabilitation programme. Among controls, predictors of new symptoms or worsening with PCS development were an intercurrent secondary SARS-CoV-2 infection and educational status. At phase 2, persistent cases were less frequently never smokers, had higher values for BMI and body fat, and had lower educational status than controls. Fatigue/exhaustion, neurocognitive disturbance, chest symptoms/breathlessness and anxiety/depression/sleep problems remained the predominant symptom clusters, and exercise intolerance with post-exertional malaise for >14 h (PEM) and symptoms compatible with ME/CFS (according to Canadian consensus criteria) were reported by 35.6% and 11.6% of persistent cases, respectively. In adjusted analyses, significant differences between persistent cases and stable controls (at phase 2) were observed for neurocognitive test performances, scores for perceived stress and subjective cognitive disturbances, symptoms indicating dysautonomia, depression and anxiety, sleep quality, fatigue, and quality of life. In persistent cases, handgrip strength, maximal oxygen consumption, and ventilator efficiency were significantly reduced. However, there were no differences in measures of systolic and diastolic cardiac function, in the level of pro-BNP blood levels or other laboratory measurements (including complement activity, serological markers of EBV reactivation, inflammatory and coagulation markers, cortisol, ACTH and DHEA-S serum levels). Screening for viral persistence (based on PCR in stool samples and SARS-CoV-2 spike antigen levels in plasma in a subgroup of the cases) was negative. Sensitivity analyses (pre-existing illness/comorbidity, obesity, PEM, medical care of the index acute infection) revealed similar findings and showed that persistent cases with PEM reported more pain symptoms and had worse results in almost all tests.

Conclusions This nested population-based case-control study demonstrates that the majority of PCS cases do not recover in the second year of their illness, with patterns of reported symptoms remaining essentially similar, nonspecific and dominated by fatigue, exercise intolerance and cognitive complaints. We found objective signs of cognitive deficits and reduced exercise capacity likely to be unrelated to primary cardiac or pulmonary dysfunction in some of the cases, but there was no major pathology in laboratory investigations. A history of PEM >14 h which was associated with more severe symptoms as well as with more objective signs of disease may be a pragmatic means to stratify cases for disease severity.

What is already known on this topic Self-reported health problems following SARS-CoV-2 infection have commonly been described and may persist for months. They typically include relatively non-specific complaints such as fatigue, exertional dyspnoea, concentration or memory disturbance and sleep problems. The incidence of this post-COVID-19 syndrome (PCS) is varying and associated with sociodemographic variables, pre-existing disease and comorbidities, the severity of the acute SARS-CoV-2 index infection, and some other factors. The long-term prognosis is unknown and may differ for different symptoms or symptom clusters. Evidence of measurable single or multiple organ dysfunction and pathology and their correlation with self-reported symptoms in patients with non-recovery from PCS for more than a year have not been well described.

What this study adds The study describes the severity of the index infection, lower educational status, no previous full-time employment, and (need for) specialist consultation or a rehabilitation programme (the latter probably due to reverse causation) as factors for non-recovery from PCS, and found no major changes in symptom clusters among PCS cases persisting for more than a year. After a comprehensive medical evaluation of cases and controls and adjusted analyses, objective signs of organ dysfunction and pathology among persistent PCS cases correlated with self-reported symptoms, were detected more often among cases with longer lasting post-exertional malaise, and included both reduced physical exercise capacity (diminished handgrip strength, maximal oxygen consumption and ventilatory efficiency), and reduced cognitive test performances while there were no differences in the results of multiple laboratory investigations after adjustment for possible confounders.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

This work was funded by the Baden-Wuerttemberg Federal State Ministry of Science and Art (grant number MR/S028188/1).

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Ethical approval was obtained from the Ethics Committee of the University of Freiburg, Engelberger Strasse 21, D-79106 Freiburg/Germany (#21/1484_1), the Ethics Committee of the Medical Faculty of Heidelberg University, Alte Glockengiesserei 11/1, D-69115 Heidelberg/Germany (#S-846/2021), the Ethics Committee at the Medical Faculty of the Eberhard-Karls-University and at the University Hospital of Tuebingen, Gartenstrasse 47, D-72074 Tuebingen/Germany (#845/2021BO2), and the Ethic Committee of the University of Ulm, Oberberghof 7, D-89081 Ulm/Germany (#337/21).

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

↵ * Co-first authors

↵ # Joint senior authors

↵ † Additional members of the EPILOC Phase 2 Study Group (in alphabetic order): Parwez Aidery (Tübingen), Daniel Bizjak (Ulm), Stefanie Bunk (Tübingen), Nadine Conzelmann (Tübingen), Stefanie Döbele (Tübingen), Lisamaria Eble (Ulm), Melanie Greibich (Heidelberg), Beate Grüner (Ulm), Lucas John (Ulm), Gerhard Kindle (Freiburg), Oliver Krumnau (Freiburg), Jessica Langel (Heidelberg), Nisar Malek (Tübingen), Moritz Munk (Ulm), Stefanie Pfau (Freiburg), Stephan Prettin (Freiburg), Hardy Richter (Tübingen), Siegbert Rieg (Freiburg), Cynthia Stapornwongkul (Freiburg), Sabine Tuma-Kellner (Heidelberg), Kay Winkert (Ulm).

Data Availability

All data produced in the present study are available upon reasonable request to the authors.

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