Teaching and Learning > DOCUMENTS

Using Case Studies

Susan Illingworth

Contextualised Scenarios or Case Studies are working examples of applied ethical problems used in teaching to highlight relevant ethical principles which are:

What counts as a case study, how it is presented and the learning and teaching objectives it serves will vary considerably. In the example provided in the pragmatic approach, the case study is presented as an extract from a research proposal. It could be used as it is, to highlight an area of particular concern to Research Ethics Committees (namely the use of animals as experimental subjects), or it could be expanded into a complete research proposal outline, with appropriate scientific detail, so that students can begin the more complex process of evaluating the scientific merits of the research and weighing them against the costs in terms of animal experimentation.

That same outline could also be expanded with the detail necessary for students to role-play an application, with some acting as scientists, some as REC members and others as animal rights campaigners.

Alternatively, it could be presented in a context that highlighted the reasoning behind the principles of reduction, replacement and refinement and used as a learning and teaching resource for the theoretical approach.

The scenarios employed in the other two case studies could be similarly represented to serve the needs of different approaches. Provided the teacher is clear about their objectives, and the way the case study operates to serve those objectives, material can be tailored to meet the needs of the subject area, the expected level of experience (of both student and the teacher), and practical constraints such as group size and number of teaching hours.

A Case Study using the Pragmatic approach

Scenario

Extract from a Research Proposal designed to test the effects of exposure to fertiliser XYZTM on kidney function.

Experimental Subjects:

100 healthy, six week old rats. Mixed sex. Approved supplier.

Maintenance:

The rats will be housed in individual plastic tanks with food and water available 24/7 in the University's purpose built facility. They will be cared for and monitored round the clock by trained and experienced staff.

Palliative Care:

Previous studies (Smith et al. (1999) suggest that rats exposed to higher levels of XYZTM may develop minor skin lesions over the last four or five weeks. Topical analgesia will be administered to minimise discomfort.

Experimental Procedure:

The rats will be divided randomly into 4 groups of 25 and exposed to varying levels of XYZTM administered in their drinking water.

Group 1 - Control (no exposure to XYZTM)
Group 2 - Exposed to 10 parts per million of XYZTM
Group 3 - Exposed to 100 parts per million of XYZTM
Group 4 - Exposed to 1000 parts per million of XYZTM

At the end of the 3 month exposure period the rats will be despatched humanely and their kidneys removed for microscopic and biochemical analysis.

Ethical Issues

This scenario is designed primarily to help the students understand the principles of reduction, replacement and refinement. This would mean asking three key questions:

  1. Reduction: Could a comparable experimental outcome have been achieved using fewer rats?
  2. Replacement: Could a comparable experimental outcome have been achieved using a cultured kidney tissue cell line rather than live animals?
  3. Refinement: If the use of live animals is appropriate, does the experiment maximise the amount of information that could be obtained from their use. Could the experiment be modified in order to produce more/better results without increasing the number of animals or causing them additional distress? Students would be expected to show an awareness that refinement might sometimes indicate using more animals, because if the numbers proposed are too few to generate statistically significant results then those few rats will have been sacrificed needlessly.

Using the Case Study with Students

Students might gain additional credit for noting the reference to previous studies, and asking whether the proposal is merely duplicating work carried out elsewhere.

An introduction to the principles of reduction, replacement and refinement can be provided by the extract alone. In these circumstances students would be asked only to:

In the absence of more information about the research, they would not be able to evaluate whether the research met the requirements of these principles.

However, for more experienced students, the extract could be expanded to provide a fully defined dummy research proposal, with all the relevant scientific background, procedures etc. filled in. Students can then be invited to review the proposal as if they were a REC member, evaluating whether the research does actually fulfil the relevant ethical criteria. This would be a more demanding task and would also be time consuming, but can be a useful format for group work.

A Case Study using an embedded approach

Scenario

Students would be asked to read the following story.

In the Name of the Mother, the Son and the Holy Ghost

It was only twenty two days since the baby's premature birth but already the sights, sounds and smells of the Special Care Baby Unit had become as the familiar to Janice as those of her own kitchen. For the first week, when her daughter had been too ill to leave her bed, Janice had had the clear plastic box and its fragile contents to herself, so that by now baby Reading seemed more like her son and her grandson. She had even named him in the privacy of her own head - calling him Paul after her much missed elder brother.

The second week had seen the first of Lisa's visits and had been a precious time of mutual support but with Week Three had come a sudden twist of discord. The medical staff had begun, through carefully phrased hints and indications, to prepare them for the likelihood that baby Reading would not see the end of his first month and after an initial half-hour of shared anguish the whispered arguments between mother and daughter had started. Janice wanted to baptise her grandson but Lisa was adamant that this would not be done.

Janice found Lisa's attitude difficult to understand; her own Catholic faith was a source of comfort at times like this, offering an assurance of the ultimate purpose of seemingly random events, and the promise of reunion in the face of imminent loss. Lisa's religious observance had been patchy since her teens but Janice blamed this on her son-in-law - a nice enough lad but as far as religion was concerned he said he was C. of E. and everyone knew what that meant. Lisa had still been keen enough to have a nuptial mass for her wedding day and in the complication-free first trimester of her pregnancy, had raised no objections to Janice's talk of the big 'Do' for the christening of the first grandchild. They had even picked out a gown for the baby - all lace and elaborate stitching - but Lisa had refused to allow Janice to buy it before the birth, saying that she didn't want to tempt fate.

Now everything had changed. Sometimes Lisa said that God wouldn't be so cruel as to condemn an innocent baby to Limbo. At other times, she said that if there was a God, why would he be so wicked as to let her baby die? At all times she was clear that there would be no anointing, no water, no 'renouncing of the Devil'. It would be like accepting that the baby had no chance at all and he did have a chance. He was getting stronger every day. The doctors didn't say that he couldn't live - only that it was touch and go. Lisa would never give up hope, no matter what her mother might say.

These were thoughts that thronged inside Janice's head as she sat beside the incubator and watched the tiny lungs battle against failing strength. Lisa was asleep on the sideward so Janice had Paul to herself for a while. She wasn't sure for how long - maybe thirty minutes - maybe an hour if she was lucky - then Lisa would be back to join the vigil and maintain a guard. Suddenly was it clear to Janice what she must do. The resolution presented itself, whole and fully formed, from the apparent chaos of her subconscious mind.

She picked up the plastic cup of water that one of the nurses had brought her earlier. Its contents were at room temperature, which meant 28°C in the overheated atmosphere of the baby unit. The only snag was that she needed to raise the lid of the incubator and was afraid of setting off the alarm.

At the other side of the room was a nurse - a tall well-spoken girl in her late twenties, and the one with whom Lisa had established the greatest rapport.

'Nurse!' Janice called softly, 'Nurse Emma'.
Emma sighed to herself and mentally postponed her cup of tea yet again.
'Yes Mrs Phillips?' she responded, padding across in sensible shoes. 'How are you doing?'.
'Coping,' Janice smiled and Emma saw exhaustion etched into every feature. 'for now at least.'

Janice hesitated, her hands squeezing the plastic cup so tightly that its contents rose up and threatened to overspill. 'I wanted to ask your favour.'.
'Of course,' the nurse replied cautiously. 'If I can.'.
'I want you to raise the lid on the incubator.' Emma said nothing but her face was eloquent with doubt and concern. 'I want to baptise him,' Janice nodded towards the sleeping child. 'Before it's too late.'
For a moment Emma maintained her silence, then she took a deep breath and began slowly,'But Mrs Phillips '
'There's no danger,' Janice interrupted, one eye on the door where her daughter might appear at any moment. 'All I need to do is pour a little water over his forehead - just drop - only the tiniest drop - and say a few words.'
'But Mrs Phillips - Janice ' Emma reached out to put a placatory hand on Janice's arm.
'It won't take long,' said Janice. 'No more than fifteen seconds.' Her voice was rising now, sensing opposition. 'The incubator is open for much longer than that when you're washing him.'
'I know but- '
'I don't need a priest or anything. My religion allows anyone to do it in extremis.'
'I know - '
'Then you must understand what it means to me - to him - to be baptised before he dies,' Janice urged. 'All I have to do is say "I baptise thee Paul" - that's the name I've given him - Paul after my brother - "I baptise thee Paul in the name of the Father, Son, and Holy Ghost". Then a little water poured over his head and it's done. What harm can it do?'
'That's not the point,' Emma said firmly. Her grip on Janice's arm changed from comfort to one of gentle control. 'Why don't you come through to the Relatives' Room? We can talk better there. Or I could call a priest to counsel you.'
'It isn't me that needs the priest' Janice wailed, tears of frustration welling into her eyes. 'And there isn't time to talk about it. Lisa could be here at any minute.'
'Yes and that is the point.' Emma stood back and folded her arms across her chest, her gaze shifting to her patient. 'I'm sorry Janice - I do understand that this is very difficult for you but you know very well that Mrs Reading doesn't want her baby baptised just yet, and she is his mother. It's her decision, not yours.'
'She doesn't mean it.' Janice took a deep breath to suppress the sobs that were constricting her throat and making it difficult to speak. 'She's angry and in pain right now, but when all this is over and the baby is dead she'll wish she'd done the right thing.'
'What about now?' Emma asked quietly. 'Shouldn't you consider what Lisa needs right now?'
'She needs her baby to live but you can't give her that and neither can I.'
'There's always hope, Mrs Phillips. And if the worst happens - well the human mind has great powers of recuperation but your daughter will need all your support. If you make her feel guilty -'
'Do you really think I would?' Janice cried. 'I'd never say a word - not when it was too late - but I wouldn't need to. Once a Catholic, always a Catholic. Her beliefs are still there, whatever she might say and in the long run it will kill her to know that she kept her son out of heaven.'
'Mrs Phillips! Please!' Emma was bitterly regretting having started this conversation and knew that she was way out of her depth. An agnostic herself, she was generally tolerant of religious belief in others, but she found Janice's acceptance of a God who would condemn a baby on such trivial grounds repugnant. 'I really think that we should go through to the Relatives Room. I'll make some tea and ask the priest come round as soon as possible. I'm sure there must be some other way to set your mind rest - '.
'There's no other way,' said Janice miserably. She thought for a moment then tried a different tack. 'What about the father?' she suggested. 'My son-in-law said he didn't mind the child going to a Catholic school -'
'All this is for Mr and Mrs Reading to decide,' Emma insisted taking Janice by the shoulder and steering her firmly towards the door. 'Now come and sit yourself down. Perhaps your daughter will agree to speak to the priest with you - it might help her if you are correct about her true feelings. But I hope you understand that we can't override Lisa's wishes in this. It wouldn't be right.'

Janice paused and made her final appeal.
'She needn't know,' she whispered. 'Let me baptise the baby now, without telling her. And I'll never tell her - not unless she regrets refusing to do it herself. Just think about Lisa and how she'll feel when she does change her mind and it's too late. Think how it will prey on her conscience. Help me now so I can help her then - I'll be able to tell her not to worry - that the baby was baptised - that he is happy in heaven. And if she never changes her mind I won't say a word - not to my dying day.'
Emma hesitated. It made a sense of a kind and she found it difficult to account for her own reluctance, but the bottom line was the parents said "No" and that was all there was to it.
'You could always lie,' she said at last.
'What?'
'If your daughter regrets not baptising the baby, you could tell her that you had done it.'
'But it wouldn't be true.'
'Would that matter if it gave Lisa peace of mind?'
Janice shook her head and admitted defeat.
'You just don't understand -- you're not a Catholic.'
'No Mrs Phillips I'm a nurse. I'm really sorry but I have to put the baby and his parents first.'
And with that she led Janice over to an armchair then went to put the kettle on.

Ethical Issues

Using the Case Study with Students

There are a number of issues that have a moral dimension in the above story, but a key difference between the embedded approach and the pragmatic and theoretical ones here is that there need be no overt reference to ethics or morality in either the story itself or the students' consideration of the story.

It may also be noted that although the nurse is asked to make a morally sensitive decision, it does not relate to an aspect of medical ethics as there is no clinical decision to be made about the best interests of the patient. It does, however, highlight the difficulty of interpreting the Duty of Care as defined in the notion of Fitness for Practice.

For example, to whom is the duty of care owed? To the baby and his mother the duty is owed in respect of their position as patients within the hospital. Lisa might claim an additional claim as the parent of a minor but what about Janice? Does she have a claim at all, and if so, is it a direct claim that the staff should consider her welfare or does she have only an indirect claim based on her contribution to the welfare of the baby and his mother? Can one formulate a general position with respect to grandparents of premature babies or can one only answer the question by reference to the individual circumstances of this case such as Janice's three-week presence on the ward, her character, and her relationship with her daughter.

These are complicated and deeply interrelated questions, and exploration via narrative formats will sometimes be the best way for students to tackle them.

Facilitators can invite students to consider whether the nurse's behaviour is defensible by reference to overtly ethical concepts and principles, but this is not essential. More important is that they explore their own reactions to the story. There are a number of prompts or questions that might be posed to help them do this:

If the narrative is presented within a group discussion format it is also worth students asking themselves: Does their reading of the story change as a result of group discussion?

An enquiry along these lines will bring out much that is ethically relevant in the students' attitudes, and the teacher may choose to bring these aspects to their attention for overt consideration. Indications that students are not applying their ethical values or principles consistently or that they have difficulty in stating the moral issues embedded within the story would identify areas where there is potential for the student to learn and enrich their capacity to behave ethically. Alternatively, if the embedded format is used to serve embedded learning objectives, the narrative would be used to explore and enrich the students conception of what it means to be 'Fit to Practice'. The ethical dimension would be examined in concert with other factors through their consideration of a story in which ethical principles and concepts are embedded, but would not be treated to separate and overt consideration. Indications that a student's conception of Fitness to Practice is incompatible with the requirements of registration as assessed at their institution, will identify areas where there is potential for the student to learn and develop their view.

A Case Study using a theoretical approach

Scenario

Consider the following two cases:

Case One: Ms X is 26 weeks pregnant. She has developed a medical condition, Z. If left untreated, Z poses a 75% risk of serious permanent damage to Ms X's health. Ms X can be cured by a single oral administration of medication Med.1, but only if it is administered immediately, before the condition has a chance to progress. A side-effect of this treatment will be the death of the foetus and a miscarriage. The foetus is currently healthy and is unlikely to be affected by condition Z, so if Ms X decides to reject treatment the prognosis for her pregnancy is that it will result in a healthy, full-term baby.

Case Two:Ms A is 26 weeks pregnant. She has developed a medical condition, B, which means that if she continues with the pregnancy there is a 75% risk of serious permanent damage to Ms A's health. The safest method of securing a termination for Ms A is a single oral administration of Med.2, which will cause the death of the foetus and induce a miscarriage. The foetus is currently healthy and is unlikely to be affected by condition B, so if Ms A decides to reject treatment the prognosis for her pregnancy is that it will result in a healthy, full-term baby.

Ethical Issues

This scenario is designed to illustrate the Rule of Double Effect (RDE).

The RDE applies in cases where an action has two outcomes, one good and one bad. It would be located within the context of a consideration of whether actions should be evaluated purely on their consequences, or whether the agent's intensions have a moral significance which should be taken into account.

Where an agent performs an action that has good and bad consequences, does it matter whether the agent directly intends the bad consequence, or whether they merely foresee it? Some moral positions argue that it does, and apply the RDE to determine whether action is permissible.

The scenario above compares cases in which the actions and their consequences are similar; in each case treatment is administered that will cure of a serious medical condition in a female patient, but which will also result in the death of a 26 week foetus that would otherwise be expected to develop into a healthy full-term baby. The cases differ with regard to the intentionality of the agent in respect of the bad effect.

Beauchamp and Childress (Beauchamp, T.L. & Childress, J.F. (1994) Principles of Biomedical Ethics, Oxford: Oxford University Press, pp. 207) identify four necessary (and, taken together, sufficient) conditions for an act with a double effect to be permissible according to the RDE:

The scenario is designed to isolate point 3 by presenting cases that are similar in all but that respect.

In Case One there is no intension to cause the death of the foetus although it is a foreseeable consequence of treatment. If Ms X were not pregnant, or if the treatment had no effect on the foetus, there would still be a clinical reason to administer Med. 1 assuming that all the other conditions remained the same.

In Case Two, the agent intends only the good effect of curing Ms A (for they would not terminate the pregnancy if Ms A did not have the harmful medical condition) but this is achieved as a direct consequence of the bad effect. The bad effect is a means to the good effect. If Ms A were not pregnant, or if treatment had no effect on the foetus, there would be no clinical reason to administer Med. 2 assuming that all the other conditions remained the same.

Case One would therefore meet the conditions for permissible action subject to the RDE. Case Two would fail condition 3.

Using the Case Study with Students

In this Case Study, the scenario is used to illustrate a single condition in a specified principle. Students would be asked to accept, for the purposes of the illustration, that the good effect of curing a medical condition which carries a high risk of serious, permanent damage to the patient's health outweighs the bad effect of causing the death of a 26 week foetus.

In practice, this view would be challenged by those who regard the foetus as having the same value and rights as the mother (which would mean that both cases failed condition 4). Conversely, it might be argued that the death of the foetus was not a sufficiently bad consequence to be considered significant in evaluating the moral consequences of treatment. Others might reject the RDE and require that the cases should be evaluated purely in terms of their consequences.

However, students are not being asked to reach a final conclusion on the moral justifiability of treatment, nor to decide what they themselves would do, but to explore how the application of the RDE might influence the outcome of the decision-making process. Using Case Studies via the theoretical approach will sometimes mean asking students to accept, for the purposes of argument or illustration, a moral position that they do not in fact hold, in order to understand the reasoning processes of people who have differing views from their own. In this case, they are asked to understand why those who regard intentions as being morally significant might make a distinction between Cases One and Two, allowing treatment to be morally justified in the first case but not the second.

Case Studies as Projects

Case studies can be offered to students as projects, to be tackled either individually or by groups of students. This can be of great benefit, especially if students have an opportunity to devote a number of weeks to the project. However, care must be taken to ensure that the group composition, in terms of both background and level, is appropriate to the demands of the case study selected.

Teaching via case study project can be used to develop a number of key skills:

Case studies can also be used to give students an insight into the roles they can have when they leave university, by exposing them to visiting experts who also function as role-models. These visiting experts can be invited to set up case studies or problems that student groups must solve by working together, and to evaluate the end result. The visitors may need training in order to perform their role effectively, especially if they are not actively involved in teaching outside their role as visitor. This training should cover:p>

This process may help to develop links between the department and potential employers. Visitors get a chance to see how the department works, form a relationship with the staff and assess the quality of teaching the department provides. Individual students who show promise in their execution of the case study might be targeted as future employees.

Group assessment of case study projects can be done by a variety of means:

Further information can be found at www.cases.bham.ac.uk/group . This material has been developed for metallurgy and materials but much of it can be adapted to the needs of applied ethics learning and teaching.

This page was originally on the website of The Subject Centre for Philosophical and Religious Studies. It was transfered here following the closure of the Subject Centre at the end of 2011.

 

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The Religious Studies Project