Microsoft word - vol6no1_new compose_by gaew 2sep2013

Original Research Paper
Validity of the Multidimensional Ethics Scale for a Sample
of Thai Physicians
D.C. Malloy1 ,2, P. R. Sevigny 3, T. Hadjistavropoulos 2, 3, Paholpak, S.4,


Research in ethical decision-making has received considerable attention in the realm of the business
community in the last three decades due in part to numerous high profile scandals (e.g., Enron). The
medical community has been less engaged in this line of investigation as the primary scholar focus
has been in biomedical as opposed to social science/humanities. However, recently researchers and
their methods have been attracted to the medical field. The purpose of this paper is to explore
whether an ethical decision-making measure prominent in the business literature can be applied to
the medical contexts.
The MES was originally developed to assess ethical decision-making in business (Reidenbach Ethics in medicine has a profoundly long & Robin, 1988; 1990). To this end, 33 items history from the early followers of Hippocrates were designed to tap into five ethical decision to the disciples of Taoism and traditional domains: Deontology, Utilitarianism, Relativism, Chinese medicine. However, it has not been Egoism, and Justice. Deontology considers until recently that a concerted effort has been ethical conduct to be duty-based in which the made to study the decision-making behaviour of physicians (Malloy et al., 2008). importance. Utilitarianism argues that the outcome is the primary goal of ethical conduct research has focused upon the perceptions immediate concern. Relativism purports that and practices of members of the business outcome and process are particular to the situation and that one must be flexible when development and use of questionnaires to deciding what is or is not ethical conduct (when in Rome do as the Romans do). Egoism (Forsyth, 1980). Of the many instruments used is individually-based and directs each of us to to assess ethical decision-making in this pursue the greatest pleasure for ourselves as context, the Multidimensional Ethics Scale a means to seek the ‘good’. Finally, justice has its roots in Aristotelian theory whereby equals (1988) has received considerable attention. The purpose of this study was to determine if the MES was a viable instrument to be used in Through the use of exploratory factor analysis (EFA), the number of items was eventually brought down to eight, measuring a total of three dimensions that combined to form the 1 Faculty of Kinesiology & Health Studies, University of final version of the MES. The first dimension is Moral Equity, representing the notion of right 2 Centre on Aging and Health, University of Regina, and wrong is a second dimension that taps into social concepts learned through experience. 3 Department of Psychology, University of Regina, Canada The final dimension, Contractualism, represents 4 Department of Psychiatry, Faculty of Medicine, Khon the notion of obligation and social contract. Reidenbach and Robin, consists of eight items Room 109 Office of Research Services, divided over three dimensions (MES-8), it has Research & Innovation Centre, been used in different variations since its University of Regina, Regina, SK, Canada, S4S 0A2, inception. For example, using the same initial South East Asian Journal of Medical Education items as Reidenbach & Robin (1990), but a Translation
different analytical approach, Hanson (1992) When conducting cross-cultural research it is dimensions. Cohen, et al. (1996) empirically derived a 12-item scale that clustered onto cultures is equivalent. To minimize the impact of language differences the questionnaire (2007) 10-item scale displayed little evidence underwent a translation and back-translation of a multidimensional structure. The numerous scenarios were originally compiled in Canada (English) and then translated by language experts in Thailand. Scenarios were then Regardless of which version has been used, translated back into English by Canadian MES has been exclusively applied within a experts. The back translations were reviewed by the research team to ensure accuracy. applicability for use with a different population, While no translation is entirely error free, we it is important to test and validate the factor believe this method minimizes the potential structure of the instrument in a sample drawn from a new population (Bollen, 1989, Byrne, Shavelson, & Muthén, 1989). This study Analyses
focuses on assessing the validity of the MES-8 The use of exploratory factor analysis was deemed appropriate for several reasons. First, as detailed previously, different factor structures have been found across studies Participants and Procedures
(Cohen, et al., 1996; Hanson, 1992; McMahon & Harvey, 2006). Second, to our knowledge Physicians in this study were participating in a this is the first study that has employed MES larger investigation exploring the cross cultural with a sample of physicians. Third, our sample influences on ethical decision making. This was drawn from Thailand which is clearly a different cultural context from the United Ethics Board of the University of Regina, Canada and Khon Kaen University, Thailand. confirmatory factor analysis was not advisable Eight hundred names were chosen at random from the national directory of physicians in due to the low number of items comprising two Thailand. A total of 319 physicians participated of the subscales of MES. At least three items in this study (39.9% response rate). Seven per subscale are needed for the validation of a scenarios were derived from ethical dilemmas multidimensional scale, (Bollen, 1989; Marsh identified by physicians during separate focus & Hau, 1999), while MES contains two subscales consisting of merely two items. description of the methodology; the scenarios Thus, seven EFAs, (one for each scenario) were conducted to assess whether the original participant burnout, four parallel questionnaire factor structure (Reidenbach & Robin, 1990) held for a sample of physicians. Many of the participant completed two of seven scenarios. earlier factors analytic studies of the MES Packet A contained scenarios 1 and 2, packet B contained scenarios, 3 and 4, packet C contained scenarios 5 and 6 and packet D speaking is a data reduction technique. Since contained scenarios 1 and 7. Age and sex of our aim was to explore the underlying factor the participants as well as the number of structure of the already distilled 8-item MES, participants who completed the MES-8 per maximum likelihood extraction is well suited for this purpose (Costello & Osbourne, 2005). Overall, 23.5% of the respondents indicated factors to be correlated (McMahon & Harvey, they were general practitioners. A cross 2007; Nguyen & Biderman, 2008) direct section of specialties is also represented with physicians self-identifying 24 different areas of specialization. Nearly all physicians (98.4%) completed their medical training in Thailand. In Similar to research by Reidenbach, Robin, and terms of religious affiliation, the vast majority Dawson (1991), multiple regressions were of physicians (95.9%) identified themselves as conducted to assess the relative impact of the three dimensions on a measure of ethical evaluation (i.e., to assess the scale’s level of criterion validity). To this end, a single item correlations between these factors are 0.7 or measuring whether the presented scenario above (See Table 3). This supports the notion was deemed ethical or unethical on a 7-point that the two factors are measuring, to a large Likert scale was included as the outcome variable. Seven multiple regressions, using the between Moral Equity and Constructualism or enter method, were conducted; one for each between Relativism and Constructualism did scenario using the data obtained from the not exceed 0.7. However, all correlations were statistically significant at p<0.05, suggesting that all three factors are strongly related to Bartlett’s test of sphericity was significant for Results of the multiple regressions showed all seven EFA’s (p<.001) and the KMO that the MES-8 is a significant predictor of the univariate measure of ethics conducted with a satisfactory (Norusis, 1988; see Table 2). The sample consisting of physicians. The scale EFAs show some varying results, although four out of seven scenarios (i.e., scenarios 1, variance in the ethical judgement measure. 2, 4, and 6), all items are clustered into one overall factor. However, there is some support The results also showed consistently that for the existence of a two-factor structure as Moral Equity was the most important predictor of the univariate ethics measure. In all cases, (scenario seven), the first two factors were Moral Equity had the largest standardized combined (Moral Equity and Relativism), while Beta, indicating its relative importance. Contractualism form to one factor. However, in Combining the results of the EFA and the this case the combined factor is by far the multiple regressions, it can be assumed that a most important factor (i.e., it explains the most large amount of variance is shared between at variance). Also, scenarios 3 and 5 showed least the first two subscales (Moral Equity and multiple cross loadings and displayed no Relativism), which can be combined into one subscale. Also, Contractualism can be considered a part of one overarching factor, combining all three original subscales. The existence of a one-factor solution, or possibly results of the multiple regressions showed that a combination of the first two factors (Moral if Contractualism was regarded as a separate Equity the Relativism) of the original MES-8. factor, its impact on the univariate ethics The latter was supported by high inter-factor correlations between the two factors. All Table 1: Participant Sample Size and Mean Age (SD) Divided by Sex, and Scenario
Male Female
South East Asian Journal of Medical Education Table 2: Factor Solutions for 8-Item MES in Seven Scenarios
Sc. 1 Sc. 2
.94 .93 .94 .70 .93 .83 .43 .79 .91 -.53 .92 .90 .89 .62 .86 1.00 .49 .83 .94 -.45 Violates - Does not violate an unwritten Note. * Results from component matrix Table 3: Correlations Between the subscales of the MES for Seven Different Scenarios
Note. * All correlations were significant at p<.05; ME=Moral Equity, Rel.=Relativism, Con.=Contractualism Discussion
to scenario selection, to ensure that the ethical dilemmas articulated in each scenario were The purpose of this study was to assess the validity of the MES-8 when completed by a sample of physicians. Our results did not Our scenarios were derived from focus group support the original three-factor structure of sessions in which physicians were asked to the MES-8 as developed by Reidenbach and describe their most commonly encountered Robin (1990), but rather a one-factor solution, ethical dilemmas (see Malloy et al., 2008). As and to a lesser extent a two-factor solution in This study, did not intentionally vary the which Moral Equity and Relativism were presented situations based on any particular combined. Four out of the seven scenarios ethical principle or moral dimension. However, given the results found in this initial study, existence of one dominating factor. This is follow up investigations could vary and assess scenario based factors in a systematic way. researchers who found weak evidence for the Conclusion
(McMahon & Harvey, 2007; Nguyen & Biderman, 2008; Tansey, Brown, et al., 1994). In conclusion, for a sample of physicians the Reidenbach and Robin (1990) suggest that MES-8 used in this study was dominated by single factor findings may reflect a construct one general factor. Even though the existence such as ethical judgment is being tapped that of Contractualism as a separate dimension has been acknowledged in this study as well philosophies. Indeed, the results of our as previous studies, its usefulness is limited regression analyses found that the MES 8 was due to the fact that it is comprised of only two a strong predictor of the ethical judgement of items (Bollen, 1989). Furthermore, compared Thai physicians. A two-factor solution similar to the combined subscale of Moral Equity and to that found in the present study was also Relativism, Contractualism has little power on predicting ethical judgment. The results of our study mirror those who have used the MES-8 within a business context. The MES-8 is seen existence of a two-factor solution, the authors as a valid instrument in assessing the ethical mentioned the natural relationship expected between what people perceive to be culturally acceptable and what is fair or just. If the References
meaning of fairness is closely related to what is deemed culturally acceptable, the two Bollen, K. A. (1989) Structural equations with latent variables, New York: John Wiley & Sons. involved subscales should be closely related. Byrne, B. M., Shavelson, R. S. & Muthén, B.(1989). religion, there may exist a more ambiguous sense of justice that would incorporate what is Covariance and Mean Structures: the Issue of culturally acceptable. The ultimate aim of Partial Measurement Invariance, Psychological Buddhism is non-violence, there may be a broader acceptance of varying cultural paths Cohen, J. R., Pant, L., W., & Sharp, D. J. (1996) leading to the end. For example, the Itivuttaka Measuring the ethical awareness and ethical states that “all the means that can be used as orientation of Canadian auditors, Behavioral bases for right action are not worth the Research in Accounting, 8 (Supp) pp. 98-119. sixteenth part of the emancipation of the heart through love. This takes all the others up into Costello, A. B. & Osborne, J. (2005) Best practices itself, outshining them in glory” (Hooks, 2007, recommendations for getting the most from p. 41). In the current exploratory study, the your analysis, Practical Assessment Research factor structure of the MES 8 was not invariant & Evaluation, 10, 7 [Online] Available at across the seven scenarios employed. This is consistent with recent studies by McMahon and Harvey (2007) and Nguyen and Biderman Forsyth, D. (1980) A taxonomy of ethical ideologies, (2008) who found that scenario based factors Journal of Personality and Social Psychology, played a significant role in understanding their MES data. It is important to note that in the present study, we used a grounded approach South East Asian Journal of Medical Education Hansen, Randall S. (1992) A Multidimensional Norusis, M. J. (1988) SPSS/PC+ Advanced Purification and Refinement, Journal of Reidenbach, R. E., & Robin, D. P. (1988) Some initial steps toward improving the measurement Hooks, B. (2007). Creating a culture of love. In of ethical evaluations of marketing activities. McLeod, M (Ed.) The Best Buddhist Writing, Journal of Business Ethics, 7, pp. 871–879. Reidenbach, R. E., & Robin, D. P. (1990) Toward Malloy, D.C. Williams, J., Hadjistavropoulos, T., the development of a multidimensional scale Krishnan, B., Jeyaraj M. Fahey McCarthy, E., for improving evaluations of business ethics, Murakami M., Paholpak, S. Mafukidze, J. & Hillis, B. (2008) Ethical decision-making about Journal of Business Ethics, 9, pp. 639–653. older adults and moral intensity: An international study of physicians, Journal of Reidenbach, R. E., & Robin, D. P., & Dawson, L. (1991) An application and extension of a multidimensional ethics scale to selected Marsh, H. W., & Hau, K. T. (1999) Confirmatory marketing practices and marketing groups, factor analysis: Strategies for small sample Journal of the Academy of Marketing Science sizes. In Hoyle, R.H. (Ed.), Structural equation modeling with small sample sizes, Newbury, Tansey, R., Brown, G., Hyman M. R., & Dawson, Jr, L. E., (1994) Personal moral philosophies McMahon, J. M., & Harvey, R. J. (2007) Psychometric properties of the Reidenbach- Journal of Personal Selling and Sales Robin Multidimensional Ethics Scale, Journal of Nguyen, N. T. & Biderman, M. D. (2008) Studying ethical judgements and behavioural intentions using structural equations: evidence from the multidimensional ethics scale. Journal of Business Ethics, 83, pp. 627-640. Appendix A: The Seven Scenarios
Scenario 1: Quality of Life – Level of Treatment Mrs. X is an 85-year-old woman with terminal cancer and in significant pain. She is not expected to live more than 30 days. The attending physician realizes that to provide her with adequate pain relief, the administration of an increased dose of morphine may result in further complications that may hasten her death. Without an increase in the dosage of her medication she will perhaps live an additional month yet suffer profoundly. Action: The physician increases the dosage of morphine.
Mr. O. is a 73-year-old retired executive who has begun to show signs of early onset of dementia. His wife reports that he is getting lost while driving his car in the city in which he has lived all his life and often loses his car after parking for short periods of time. Mr. O. vehemently denies that he has memory issues and diverts blame to improper placement of street signs. Following testing that confirms dementia, Dr. M. must decide whether or not Mr. O. is a driving hazard due to his declining mental faculties. Action: Dr. M calls the motor vehicle department to rescind Mr. O’s license to drive.
Mrs. E, a 93 year-old former nurse, is terminally ill with colon cancer, is in considerable pain, and wishes to die. Her daughter, Mrs. D who has been caring for her, accepts the impending death and is prepared to do everything she can to let her mother pass away in peace. Mr. E, the son, who not seen his mother in 3 years, insists that everything possible is done to continue his mother’s life and threatened legal action if the extraordinary measures were not carried out. Action: The attending physician indicated to the staff that Mrs. E should continue to receive pain
medication and all other interventions to remain passive.
Mr. R has brought his 67-year-father to the physician’s office to receive the results of tests performed earlier in the year – early onset of dementia is suspected. Before taking his father into the examining room, Mr. R speaks to the physician privately and requests that if there is any bad news (i.e., confirmed dementia) that his father not be informed because the news will be devastating to him and it is ultimately a family obligation. Action: The physician does not tell the patient that he is developing dementia.
Mr. V. is an 83-year-old patient who suffers from trigeminal neuralgia. He has been prescribed
neurontin – a relatively new and expensive medication that will significantly reduce the chronic pain
that he experiences. The cost of continuing treatment is considerably high for his only son to bear.
His son requests that another less expensive, over the counter medicine (possibly much less
effective) drug be prescribed to his father.
Action: The physician changes the prescription to the less expensive drug.
South East Asian Journal of Medical Education A 78-year-woman suffering severe pain due to terminal cancer has an acute heart attack and is rushed to emergency. She has provided the hospital with a Do Not Resuscitate order. The emergency doctor is a devout Christian and does not believe in concept of DNR. He believes God gave him the gift of saving lives and thus his duty is to do all he can to serve God in this manner – no exceptions. Action: The physician ignores the DNR and brings the patient back to life.
Scenario 7: Witnessing Inappropriate Treatment Dr. B works in a government funded palliative care home. This institution is profoundly under-funded and as a result under-staffed. Many patients suffer from dementia and are prone to wandering around in the compound and often “escape”. In order to prevent residents from leaving their room, restraints have been used. However, recently the media reported on this practice and a public outcry ensued. Despite her reluctance to use restraints, Dr. B realized that the patients had to be confined for their own good. Action: Dr. B began sedating the more active patients to limit their mobility

Concerning the choice of an EFA over a CFA: A CFA was not possible due to the low number of items
per subscale. Bollen (1989) recommends not using subscales with two items in a CFA. A case can be
made that, because the MES has been used in different variations since it has been introduced, an
EFA is legitimate.
Gorsuch (1983, p.332) recommends a minimum subject to item ratio of at least 5:1 in EFA, but also
notes that higher ratios are generally better. On the other hand, Nunnally (1978, p. 421) recommends
that the subject to item ratio for exploratory factor analysis should be at least 10:1.
Next, to check the dimensionality of Forsyth's taxonomy, a maximum likelihood factor analysis of his EPQ items was done (Gorsuch 1983; Norusis 1990); when trying to determine latent structure, Cureton and D'Agostino (1983) recommend a maximum likelihood factor analysis over a principal components factor analysis. First, Forsyth’s (1980) two-dimension (Idealism and Relativism) ethical positioning scale was tested through CFA with LISREL 8.54 (Jöreskog & Sörbom, 2000) for its applicability in each of the five different socio-cultural contexts. This also served as the precursor to testing cross-cultural measurement equivalence of the scale at a later stage because the scale should be valid for each sample before further test of cross-cultural invariance of the scale simultaneously across the five samples (Bollen, 1989; Byrne et al., 1989; Steenkamp & Baumgartner, 1998).


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