PONE-D-22-03571Contextualizing sacrificial dilemmas within COVID-19 for the study of moral judgmentPLOS ONE

Dear Dr. Blanc,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

This manuscript has potential. Yet, especially reviewer one has major concerns that have to be taken in consideration and properly addressed before I can take a decision on publication. Also the point raised by the second reviewer is not minor. The request is for very significant revisions. 

Please submit your revised manuscript by May 02 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Sara Rubinelli

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: I Don't Know

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The experiments conducted are very interesting but I have some doubts about their methodology and purported realism, which is very important given that that’s the topic under investigation.

Lengthy introduction gives useful introduction to the literature in this area. However, there are a few shortcomings, mainly from the ethical perspective:

The language used here presents utilitarianism as unethical/an opponent of ethics. “From an ethical point of view” should say “from a deontological” point of view, or some other moral system. “From a utilitarian point of view, approving the sacrifice of one life in order to save the lives of five others is morally acceptable with respect to the number of lives saved. By contrast, from an ethical point of view, it is not acceptable to sacrifice the life of one person in order to save others because the value of each human life is paramount and no one has the right to sacrifice a life.”

It's not the “footbridge dilemma”, it’s the most famous variation of the trolley problem. And “Someone is standing on the tracks of a bridge” doesn’t make sense.

Why use the fat man example rather than the classic trolley problem? Using the fat man example instead makes it sound like you intended people to die when you deny them an intensive care bed, whereas that’s not the case.

More argumentation is needed to back up the claim that “emotion makes utilitarian decisions harder to make”. For many people the utilitarian choice is justified by an appeal to emotion.

Also, people might intuitively believe that they should act deontologically, but later on reflection regret not making the utilitarian decision.

It’s true that the footbridge dilemma is unrealistic. However the main trolley problem is much more realistic and that’s another reason it should be used in this paper instead.

Again, the “switch dilemma” isn’t “a version of the trolley problem”, it IS the trolley problem.

One drawback of the VR approach is that it risks making the experiment seem more like a game than an abstrac scenario.

I’m not the greatest fan of trolley problems, but it’s overstating it to say ““trolley problems are unrealistic and unlike anything people encounter in the real world”. Anyone who has swerved the car to avoid a squirrel or fox, putting their family at risk, has experienced a real life trolley problem. And as you argue in the paper, doctors on the ICU face similar issues.

Doctors have always been making ‘moral decisions about which patients to admit to the Intensive Care Unit (ICU) and for which ones to provide lifesaving resources” regardless of the pandemic.

ICU sacrifical dilemmas might seem more realistic than trolley problems, but they’re often greatly oversimplified in a way that makes them clinically unrealistic, even if they seem real to members of the public.

The footbridge dilemmas is also implausibly because it seems unlikely the decision-maker could life/shove such a heavy person, and also because there would be no way of knowing whether he would stop the train or not. In contrast, the main trolley problem is much more plausible as it lacks these “stupid” features.

Why were those who had lost a relative to Covid excluded after participation rather than before, if the criterion was decided before collection? That means that their time was wasted. An ethics committee would have picked up on this if the study had been reviewed.

The triage dilemma used in study 1 is unrealistic, at least compared to the ICU bed example. Hardly any hospitals ran out of oxygen and none that I’m aware of ran out of antibiotics. Given the emphasis on plausibility this is unfortunate. The oxygen example also differs from antibiotics (and the ICU bed) because it’s normaly certain that a patient will die without oxygen but that’s not the case for the other two. In addition, the antibiotics example seems implausible because five patients would need five times as much antibiotics as one patient, and antibiotics courses need to be taken for days. To me the oxygen scenario is less plausible than the ICU bed one, but the antibiotic one is deeply implausible which is a major issue given that it was used only in the example that’s supposed to be less plausible for the reason that it’s decontextualised. This highlights that it seems to be a methodological flaw to have oxygen in the contextualised example, but antibiotics in the noncontextualised one? That introduces an unnecessary variable that could act as a confounder. Also, looking at the examples it’s clear that they’re both contextualised; it’s just that one is a fictional and one a real-world context.

“Participants were asked to be as honest as possible in their 335 responses, knowing that there was no right or wrong answer.” Were participants told that there is no right or wrong answer in ethics? That’s a very contentious morally relativistic statement that many ethicists would disagree with.

The results section is very short and could use more textual description of the results.

Also, it would probably make sense to describe the Methods of both studies in one section, the Results in another, and then have a combined discussion.

It seems rather problematic to characterise a scenario where the outcome is uncertain as less plausible; in real life the outcome is often uncertain, ie, the more uncertain the more realistic it is. Yet the authors say “In the implausible versions of the dilemma, the consequences of the utilitarian option were not certain”; to me, that sounds very plausible.

Why does the “plausible” version of the Covid-19 scenario in study 2 say “a virus

causing respiratory irritation” rather than stating that it’s Covid-19?

The only difference between the plausible and implausible versions is the added explanation at the end. To many people that part would be obvious, so it’s not clear how it can be used to differentiate based on plausibility.

Also, it’s extremely implausible to say that “this solution guarantees a 100% probability of saving them” – there’s never a 100% probability of saving any patient, much less one who needs oxygen on the intensive care unit, where around half of patients die.

The same problem applies to the plausible version of the antibiotics example – it remains extremely implausible and the explanation that’s designed to increase plausibilty actually descreases it by making implausible statements. However, the antibiotic example because, while denying oxygen will almost certainly kill a patient, providing antibiotics only increases chances of survival.

Telling participants that one option guarantees 100% that five lives will be saved clearly reduces real-world plausibility, but increases certainty and makes the choice easier.

Given all these issues, I’m not sure how valid any of the results are.

“On the other hand, they might choose to act or not to act mainly according to the outcomes they could reasonably expect (i.e., “saving a maximum 618 number of lives”), rather than following their moral considerations”

Once again, this implies that utilitarian principles don’t count as moral considerations. A utilitarian would regarded maximising lives saved as the moral and ethical thing to do. The fact that a deontologist would disagree doesn’t mean that the utilitarian is wrong or unethical.

“Our results reveal that if taking [the oxygen / antibiotics] of one patient saves with certainty the five and if there is no other way (via alternative actions) to save them, people tend to be more utilitarian in their choice of action than when the consequences are uncertain and alternative actions exist.”

Of course they do – but certainty is deeply implausible, which is problematic for this study,.

Reviewer #2: These authors have conducted two experiments to explore factors that may affect hypothetical moral responses and actions. With regard to their finding that the respondents view the COVID-19 scenario as more realistic than the antibiotic scenario, it seems quite clear that the difference is attributable to the current pandemic. From my perspective as a clinician ethicist, those two scenarios are ethically indistinguishable. It is interesting that people tended to say that they would be more likely to act than to say that action was morally appropriate. The impact of certainty of the ability of action to save more people makes sense and adds support to existing literature. I found the authors' decision to divide the methods, results, discussion into two parts to be quite odd. They should unite them into one.

I am confused about one thing -- you said that consent is not required but you obtained it from the students. that seems desirable but inconsistent.

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Reviewer #1: No

Reviewer #2: No

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PONE-D-22-03571R1Contextualizing sacrificial dilemmas within COVID-19 for the study of moral judgmentPLOS ONE

Dear Dr. Blanc,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

One of the reviewers is still not satisfied with the revision and makes important comments on how to further revise the paper. Please also check the English professionally, as it should be improved. The introduction also needs to be shortened and made more compelling. 

Please submit your revised manuscript by Jul 15 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Sara Rubinelli

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: (No Response)

Reviewer #2: Partly

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #2: I Don't Know

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: (No Response)

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #2: Ultimately, I am not sure whether this adds significantly to the literature. I understand the difference between judgment and choice of action, but the problem is that the choice of action in this setting is only hypothetical. What one should care about is what people actually do when confronted with the dilemma. It is helpful that the authors assessed the perceived realism of their scenarios, but distressing that the scenarios made so little difference. Rereading this, I have further methodologic concerns. They need to say, first, what their recruitment and exclusion criteria were (and justify the latter, which was not done; it may not have been justifiable to exclude them only after they had already been asked to revisit their loss) and then they need to say what their analytical strategy was -- as it is, it reads almost like data mining (I hate to say it). And what I wanted you to do was present Experiment1 and then Experiment 2 and then discuss them together -- as it was, there was a good bit of redundancy. Moreover, unlike Reviewer 1, I thought that the introductory literature review was way too long.

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Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Contextualizing sacrificial dilemmas within COVID-19 for the study of moral judgment

PONE-D-22-03571R2

Dear Dr. Blanc,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Sara Rubinelli

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: (No Response)

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

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