Background

Ethics is a branch of philosophy and a vast idiom covering studies from moral nature to moral decision making [1]. The significant developments in science, medical, and environmental technologies in the present era have resulted in discussing and exchanging views on ethical issues and decision-making [2].

Medical Science professionals need ethical knowledge as a guideline. They are required to abide by ethics in any circumstance. In other words, ethics is one of the fundamental parts of Clinical Sciences [1].

Medical sciences students must adhere to ethics with respect to patients’ values and needs [3]. ethical decision-making is applied to the totality of the decision-making process resulting from the detection of ethical issues through moral reasoning [4]. In moral dilemmas that put moral matters in conflict, ethical decision-making results from analyzing possible approaches and assessing possible acts to make a conscious decision to participate in an action [5]. Hence teaching moral reasoning alongside moral principles is vital [4]. Several factors can affect the ethical decision-making process (e.g., cultural differences, religious beliefs, experience, age, individual differences, commitment, mental health, and the individual’s sensitivity) [6].

Furthermore, many researchers believe that ethical decision-making is not merely the result of moral reasoning, but mediating factors such as emotions, motivation, mental health, and social factors play a part as well [7]. Nonetheless, the relationship between the aforementioned variables and ethical decision-making is not constant; since many studies show conflicting results [8]. Hence, with regards to the position of students of Medical Sciences and their vital role in community health, we performed this structural equation model to determine the components affecting moral decision-making.

Methods

This descriptive-analytical study was conducted on all available university students of Alborz University of Medical Sciences in Alborz province, Iran, in 2021.

Results

In the present study, 1235 students comprising of 237 medicine, 276 nursing, 261 midwifery, 229 anesthesiology and 232 operation room students were evaluated. Questionnaires were sent to all the 1235 students and all were gathered due to our consistency in data collection. The average age of the participants was 24.6 ± 3.8 ranging from 20 to 40 years. The average scores of the ethical decision-making, moral reasoning, mental health, and moral sensitivity were 63.3, 118.6, and 52.6, respectively (Table 1).

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Table 1. Demographic information distribution in clinical students of Alborz University of Medical Sciences.

https://doi.org/10.1371/journal.pone.0297494.t001

The Pearson correlation test results showed that moral sensitivity, moral reasoning, mental health, and SES were significantly correlated with moral decision-making. In between the variables, moral sensitivity had the highest positive correlation (r = 0.527), and SES had the highest negative correlation (r = -0.121) with ethical decision-making (Table 2).

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Table 2. Pearson’s correlation between age, education, number of passed academic and clinical semesters, moral reasoning, sensation, mental health, SES and ethical decision making.

https://doi.org/10.1371/journal.pone.0297494.t002

The path analysis test results showed that all variables were significantly correlated with ethical decision-making in one or both paths. Moral reasoning was the only variable with a single, significant positive path (B = 0.40). Variables such as age, mental health, number of passed clinical semesters, the number of passed academic semesters, and moral sensitivity were significantly correlated with ethical decision-making both direct and indirectly.

The number of clinical courses passed, moral sensitivity, and the total number of passed academic semesters had the greatest positive and negative association with ethical decision-making. (B = 0.54), (B = 0.524) and (B = -0.11) (Table 3). Furthermore, the path diagram for the association of socio-demographic parameters, moral sensation and moral reasoning with ethical decision making in the students is illustrated in Fig 1.

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Fig 1. Path diagram for the association of socio-demographic parameters, moral sensation and moral reasoning with ethical decision making in the students.

MR = moral reasoning, MD = moral decision, MS = moral sensitive, TERM = total number of passed semesters, TERMB = number of passed semesters in hospital, EDU = education, GHQ = general Health Questionnaire.

https://doi.org/10.1371/journal.pone.0297494.g001

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Table 3. Direct and indirect effects of socio-demographic parameters, moral sensitivity and moral reasoning with ethical decision making in the students.

https://doi.org/10.1371/journal.pone.0297494.t003

The results of the fitness model indices indicate the desirability, high proportionality of the model, and the logic of the adjusted relations of the variables based on the conceptual model. Accordingly, the fitted model has no significant difference from the conceptual model (Table 4).

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Table 4. The fitness model.

https://doi.org/10.1371/journal.pone.0297494.t004

Discussion

The findings of this study showed that ethical decisions are associated with several components.

Based on the study results, total passed academic semesters can directly decrease ethical decision-making; however, the number of passed clinical semesters increases the level of ethical decision-making. Based on these results, the presence within clinical courses is more important than the total passed academic semesters for the sake of ethical decision-making. Peirce et al. believe that the nature of reasoning is to consider what we have already learned and know and what we do not know. This subject is a reality and is not a reflection of an ideal subject based on results, and this is only possible when we are put in an actual situation and not just have an idea of the situation [15]. Clinical students face situations in which every decision that they make can affect the life of their patient; it is in these circumstances that they can learn moral reasoning and understand the fundamental aspects of ethics [16, 17].

Qin Chen et al. also reported that individual and social characteristics are the main difference in ethical decision-making, and the more thorough the methods of clinical education are, the students’ ability in ethical decision-making increases [18].

In this study, moral sensitivity had a positive direct and indirect association with ethical decision-making. Hence moral sensitivity had a direct relationship with moral reasoning. Moral sensitivity is considered as the combination of awareness of the moral dimension (e.g., peace and prosperity, responsibility, attending to ethical issues) that reflects the concerns of a person regarding their actions towards others and helps them to find the correct path [19].

Lützén et al. believe that students’ moral sensitivity results in timely recognition of the patients’ problems, and thus the appropriate action in a timely manner towards treatment can be taken [20]. Furthermore, research shows that professional nurses with a higher level of moral sensitivity are better caregivers and are more respectful with their colleagues [21].

Regarding the positive correlation of moral reasoning with the level of ethical decision-making found in this study, Moral reasoning can be a response to how to behave in a real or hypothetical moral dilemma. For example, in a situation merged with the rules and principles of ethics in which choosing an answer is necessary, a judgment or assessment regarding the ethical acceptability of actions or the moral qualities of others. (e.g., the judgment of individuals, groups, or institutions). [22] in general, moral reasoning is the ability to select a solution among several solutions in a moral dilemma [23]. A study by Joolaee et al. revealed that during caregiving, nurses consider ethical dilemmas; however, the lack of proper support and ethical instructions results in inadequacies in moral reasoning and ethical decision making [24]. Also, Sari et al. found that students with a lower level of moral reasoning have difficulties in ethical decision-making [25]. Furthermore, Ashoori et al. found a significant relationship between ethics, moral reasoning, and ethical decision-making in nurses as well [26].

This study found that mental health has a positive relationship with moral decision-making, whether directly or indirectly. A decisive ethical decision requires a proper level of mental health [27]. Ebrahimi et al. evaluated the psychological reactions of nurses regarding ethical decision making; they found that ethical decisions from which the patients benefit, results in positive psychological reactions in nurses (e.g., satisfaction sensation, increased motivation, and sense of competence); nonetheless, inadequacies and unfavorable results and negative outcomes result in adverse psychological reactions (e.g., stress, anxiety and depression, dissatisfaction, decreased motivation and demerit) [28].

Conclusion

Based on the findings of the moral reasoning test, moral sensation was associated with ethical decision-making, which indicates the necessity of attending to ethical aspects, promoting moral reasoning, sensitivity, and students’ accuracy.