Facilitating Healthcare Ethics Research: Assessment of Moral Reasoning and Moral Orientation from a Single Interview DONNIE J. SELF and JOY D. SKEEL
Introduction In recent years, the theoretical work of Gilligan in women's psychological development has led to the development of the concept of moral orientation or moral voice in contrast to the concept of moral reasoning or moral judgment developed by Kohlberg.1'2 These concepts have been of particular interest in gender studies, especially as applied to adolescence. These concepts of moral orientation and moral reasoning are being increasingly employed in healthcare ethics studies in a wide variety of settings. The recent work has included studies of physicians, nurses, dentists, veterinarians, social workers, teachers of medical ethics, and hospital ethics committees.3"10 However, the study of moral development in healthcare providers has been hampered because collecting the necessary data from healthcare workers has been labor intensive and extremely time consuming. More efficient methods are needed. Increased interest in the relationship of moral reasoning and moral orientation has resulted in projects that assess both in the same research subjects.11"13 Traditionally, however, research in moral reasoning and moral orientation has typically required approximately 1-1 \ hours for the moral reasoning interview and another 1-15 hours for the moral orientation interview for each research subject. Thus, projects interested in both moral reasoning and moral orientation would require 2-3 hours of interview for each research subject. Because such a time commitment seemed too much to ask of many research subjects, especially healthcare providers, attention has been directed toward combining the interview instruments so that a single interview could simultaneously assess both moral reasoning and moral orientation in no more than \-\\ hours. Over the last 25 years, the theoretical work of Kohlberg in cognitive moral development has led to hundreds of studies around the world assessing the moral judgment or moral reasoning of a great variety of people in a wide range of circumstances, from public schools to prisons.14 His research led to the establishment of his well-known stage theory of three levels and six stages of moral development, which has been described and summarized elsewhere.15'16 Various criticisms of the theory, particularly by Gilligan, later led Kohlberg to refer to justice reasoning rather than moral reasoning because he acknowledged that the concept of justice was the foundation for his moral theory. Nevertheless, in the field of moral development theory the notion of moral reasoning is still the prevalently This project was funded in part by grants from the United Ministries in Education, the United Church Board for Homeland Ministries, and the American Medical Association's Division of Medical Education Research and Information whose generous support is gratefully acknowledged and appreciated. We also acknowledge Professor Jerome Trzeciakowski for his assistance with the statistical analysis. Cambridge Quarterly of Healthcare Ethics (1992), 4, 371-376. Printed in the USA.
Copyright © 1992 Cambridge University Press 0963-1801/92 $5.00 + .00
371
Donnie J. Self and Joy D. Skeel
used concept, with the assumption of justice as the basis of morality. The work of Gilligan and Noddings has presented a serious challenge to that assumption with their claim that care is the basis of morality, especially for females.17'18 Although subsequent instruments based on Kohlberg theory have been developed, most notably the Defining Issues Test (DIT) of Rest19 and the Socio-moral Reflection Measure (SRM) of Gibbs,20 the most accurate instrument of assessment of moral reasoning has been the original oral Moral Judgment Interview (MJI) of Kohlberg.21 In her work, Gilligan has pointed out that the way people choose to frame a moral problem or the interpretation they place on the context in which it is embedded creates an organizing framework for moral decisions that is equally as important as the logic of the reasoning and ultimately influences the solution chosen and the way it is understood as a moral issue. The two organizing frameworks she has identified have been that of an orientation of justice and an orientation of care. The orientation of justice characterizes relationships in terms of equality and inequality, whereas the orientation of care characterizes relationships in terms of attachment and detachment. Similarly, the justice orientation links vulnerability to oppression and is mainly concerned with issues of fairness, rights, standards, and principles, whereas the care orientation links vulnerability to abandonment and is mainly concerned with issues of connectedness, attachment, and the effects an act will have upon relationships. Although the instrument for assessment of moral orientation was initially constructed from research in women's psychological development, it has been evolving in recent years, and various versions of the main real-life dilemma interview have been employed in a series of studies assessing moral orientation in both males and females.22'23 Description of the Instrument In this project, an interview instrument was developed called the Moral Reasoning/Orientation Interview (MROI) by combining parts of the standard Kohlberg MJI and parts of the Gilligan Real-Life Moral Conflict and Choice Interview into a single instrument. The instrument was originally developed for a project involving highly educated adult research subjects, namely philosophers and theologians who teach medical ethics and who would reasonably be expected to exhibit high stage moral reasoning. Therefore at Kohlberg's suggestion, one dilemma, the life dilemma, was taken from Form A and Form B of the standard MJI and combined with the law dilemma from Form B. Parts of the Gilligan interview focusing on real-life dilemmas were incorporated and other parts focusing on how one sees oneself were omitted. Parts of the Johnson interview using Aesop's fables were included as a backup for assessing moral orientation in case the real-life dilemmas were insufficient on some occasions for determining moral orientation.24 However, this segment of the interview has not been necessary, thus rendering the prospect of reducing the time of administration even further. Furthermore, a cross check to determine the accuracy and validity of assessing moral orientation by the fable method compared with the real-life dilemma method has not yet been carried out. A copy of the MROI can be obtained by contacting the authors. Results Once the instrument was completed, the MROI was tested to see if it would indeed provide moral reasoning stages and moral orientation in a single interview 372
Healthcare Ethics Research
Table 1. Agreement of Subject Moral Reasoning Stage Scores as Analyzed by Two Different Scorers
n Project 1 Project 2a a
Exact agreement
Agreement within 1/3 of a stage
67% 75%
100% 100%
Only eight transcripts were double scored.
of no more than \\ hours. On two occasions, a pilot project of 3 interviews and a larger project of 16 interviews, the MROI has functioned satisfactorily. Colleagues of Kohlberg and Gilligan who had extensive experience in analyzing these types of transcripts found the instrument provided the data necessary for both moral reasoning stages and moral orientation. The interviews ranged from 1 hour to \\ hours, averaging l | hours, including the use of the Aesop's fable method in addition to the real-life dilemma. In the pilot project, the three transcripts of the interviews were analyzed independently by two experienced scorers (not the authors) for moral reasoning stages based on the 1987 published scoring manual.25 In 67% of the cases the scores were in exact agreement and in 100% of the cases the scores were within 1/3 of a stage of each other, which is a generally acceptable range of variation (Table 1). Similarly, the transcripts of the interviews were analyzed independently by two experienced readers for moral orientation (not the authors nor the scorers for stages) based on the 1987 prepublication reading guide.26 In this case, the results of the readers' analyses were in complete agreement for presence of an orientation of justice or care in 67% of the cases and were reconcilable between the two readers in 100% of the cases (Table 2). However, analysis for predominance of an orientation brought complete agreement in only 33.33% of the cases, although reconciliation of predominance was 100% between the two readers. There was complete agreement on alignment of orientation (i.e., articulation of both orientations by the interviewee with endorsement of one and rejection of the other) in 100% of the cases.
Table 2. Comparison of Subject Moral Orientation Analyses by Two Different Readers Orientation Orientation Orientation presence predominance alignment Complete Reconcilable Complete Reconcilable Complete Reconcilable agreement interpretations agreement interpretations agreement interpretations Project 1 Project 2
66.67% 81.25%
100% 93.75%
33.33% 62.50%
100% 81.25%
100% 68.75%
87.50%
373
Bonnie ]. Self and Joy D. Skeel
In the larger project of 16 interviews, the two experienced scorers of moral stage reasoning obtained exact agreement in 75% of the cases and were within 1/3 of a stage of each other in 100% of the first half of the cases. In light of the 100% agreement from the pilot project and the first half of the cases in the larger project, the last half of the cases in the larger project were not double scored. In the analysis for moral orientation, however, both readers analyzed all 16 transcripts. The agreement on presence of orientation was much closer, with complete agreement in 81.25% of the cases and reconcilable interpretations in 93.75% of the cases. In the other 6.25% of the cases, the two readers just agreed to disagree because neither one could present evidence from the transcripts that was persuasive to the other. Analysis for predominance of orientation was likewise much closer, with complete agreement in 62.50% of the cases and reconciliation in 81.25% of the cases. There was complete agreement on alignment of orientation in 68.75% of the cases, with reconciliation in 87.50% of the cases. Although neither the complete Form A or Form B was incorporated into the MROI, there seemed to be no reason to doubt the adequacy of determining moral stages from the MROI. This issue, however, was tested by having a series of 10 subjects take the standard Form A of the MJI and the MROI for comparison. When scored separately by the same scorer (not the authors), no significant differences (p < .5975) in the scores were found between the two different forms for assessing moral reasoning (Table 3).
Table 3. Comparison of MJI and MROI for Assessing Moral Reasoning Subject IDa 1A IB 2A 2B 3A 3B 4A 4B 5A 5B 6A 6B 7A 7B 8A 8B 9A 9B 10A 10B a
Stage score
WAS scoreb
4.5 4.5 4.5 4.5 4.0 3.5 4.0 4.0 3.5 3.5 4.0 4.0 4.5 4.5 4.0 3.5 4.0 4.0 4.0 4.0
450 436 457 464 379 371 400 394 360 329 396 380 475 459 405 372 400 395 413 387
A = Moral Judgement Interview (MJI); B = Moral Reasoning/Orientation Interview (MROI). b WAS (Weighted Average Score) is a continuous score that ranges from a possible low of 100 to a maximum of 500 and is correlated to the stages in Kohlberg's cognitive moral development theory for determining the stage score.
374
Healthcare Ethics Research
Discussion The data generated by the MROI in this project concerning moral reasoning stages fit well with those of other studies regarding the ability to generate reliable, predictable, and reproducible stages from oral interviews with subjects. However, the data generated by the MROI concerning moral orientation may indicate the evolving nature of the system of analysis of moral orientation and the preliminary stage of the reading guide or may simply reflect the state of the art of determining moral orientation, which has not yet had the advantage of going through the 25 years of revision and refinement that the scoring manual and system of assessing moral stages of reasoning have experienced. Assessing both moral reasoning stage and moral orientation in a single interview poses a problem, especially for the assessment of moral orientation. Because the MROI was constructed from part of the Kohlberg interview format and part of the Gilligan interview format, the introduction of the Kohlberg questions first may bias the subject toward a justice orientation, whereas the introduction of the Gilligan questions first may bias the subject toward a care orientation. This influence could be determined by alternating which questions are introduced first and comparing the results. A study is underway to determine the existence and extent of this potential bias problem. Conclusion An instrument has been developed that will adequately provide data and will greatly facilitate studies of the relationship of moral reasoning to moral orientation and studies of each factor alone for correlation with other characteristics. With the MROI, studies that could correlate the moral orientation obtained by the Aesop fables (a technique previously used only with children) with the moral orientation obtained by the real-life dilemmas can more easily be conducted. Because the Aesop fable technique is much simpler and quicker and is less threatening, it may become an interesting refinement in the process of assessment of moral orientation.
Notes 1. Gilligan C. In a Different Voice: Psychological Theory and Women's Development. Cambridge, Massachusetts: Harvard University Press, 1982. 2. Colby A, Kohlberg L. The Measurement of Moral Judgment: Vol. I, Theoretical Foundations and Research Validation. New York: Cambridge University Press, 1987. 3. Sheehan TJ, Husted SDR, Candee D, et al. Moral judgment as a predictor of clinical performance. Evaluation and the Health Professions 1980;3:393-404. 4. Crishom P. Measuring moral judgment in nursing dilemmas. Nursing Research 1981;30:104-10. 5. Bebeau MJ, Rest JR, Yamoor CM. Measuring dental students' ethical sensitivity. Journal of Dental Education 1985; 49:225-35. 6. Self DJ, Safford SK, Shelton GC. Comparison of the general moral reasoning of small animal veterinarians vs. large animal veterinarians. The Journal of the American Veterinary Medical Association 1988;193:1509-12. 7. Self DJ, Jecker NS, Baldwin DC Jr, et al. Moral orientations of justice and care among veterinarians entering veterinary practice. The Journal of the American Veterinary Medical Association 1991;199:569-73. 8. Dobrin A. Ethical judgments of male and female social workers. Social Work 1989;34:451-5.
375
Donnie J. Self and Joy D. Skeel 9. Self DJr Skeel JD. A study of the foundations of ethical decision making of clinical medical ethicists. Theoretical Medicine 1991; 12:117-27. 10. Dugan DO. Masculine and feminine voices: making ethical decisions in the care of the dying. The Journal of Medical Humanities and Bioethics 1987;8:129-40. 11. Walker L, de Vries B, Trevethan S. Moral stages and moral orientations in real-life and hypothetical dilemmas. Child Development 1987;58:842-58. 12. Bebeau M, Brabeck M. Integrating care and justice issues in professional moral education: a gender perspective. The Journal of Moral Education 1987; 16:189-203. 13. Self DJ, Skeel ]D, Jecker NS. The moral development of clinical medical ethicists: the influence of philosophical vs. theological education. Academic Medicine (submitted). 14. Snarey JR. Cross-cultural universality of social-moral development: a critical review of kohlbergian research. Psychological Bulletin 1985;97:202-32. 15. Kohlberg L. Moral stages and moralization: the cognitive developmental approach. In: Lickona T, ed. Moral Development and Behavior: Theory, Research, and Social Issues. New York: Holt, Rinehart and Winston, 1976:31-53. 16. Self DJ, Wolinsky FD, Baldwin DC Jr. The effect of teaching medical ethics on medical students' moral reasoning. Academic Medicine 1989;64:772-6. 17. Gilligan C, Attanucci J. Two moral orientations: gender differences and similarities. Merrill-Palmer Quarterly 1988; 33:223-37. 18. Noddings N. Caring: A Feminine Approach to Ethics and Moral Education. Los Angeles: University of California Press, 1984. 19. Rest JR. Development in Judging Moral Issues. Minneapolis: University of Minnesota Press, 1979. 20. Gibbs JC, Widaman KR Social Intelligence: Measuring the Development of Sociomoral Reflection. Englewood Cliffs, NJ: Prentice-Hall, 1982. 21. Kohlberg L. Essays on Moral Development: Vol. II. The Psychology of Moral Development. New York: Harper and Row, 1984. 22. Lyons N. Two perspectives: on self, relationships, and morality. Harvard Educational Review 1983;53:125-45. 23. Gilligan C, Johnston D, Miller B. Moral Voice, Adolescent Development, and Secondary Education: A Study at the Green River School. Cambridge, Massachusetts: Center for the Study of Gender, Education, and Human Development, Harvard University, Monograph #3, 1988. 24. Johnston K. Adolescents' solutions to dilemmas in fables: two moral orientations —two problem solving strategies. In: Gilligan C, Ward JV, Taylor JM, eds. Mapping the Moral Domain. Cambridge, Massachusetts: Center for the Study of Gender, Education and Human Development, Harvard University/l985:49-71. 25. Colby A, Kohlberg L. The Measurement of Moral Judgment: Vol. II, Standard Issue Scoring Manual. New York: Cambridge University Press, 1987. 26. Brown L, Argyris D, Attanucci J, et al. A Guide to Reading Narratives of Moral Conflict and Choice for Self and Moral Voice. Cambridge, Massachusetts: Center for the Study of Gender, Education, and Human Development, Harvard Graduate School of Education, Monograph #1, 1987.
376
Introduction In recent years, the theoretical work of Gilligan in women's psychological development has led to the development of the concept of moral orientation or moral voice in contrast to the concept of moral reasoning or moral judgment developed by Kohlberg.1'2 These concepts have been of particular interest in gender studies, especially as applied to adolescence. These concepts of moral orientation and moral reasoning are being increasingly employed in healthcare ethics studies in a wide variety of settings. The recent work has included studies of physicians, nurses, dentists, veterinarians, social workers, teachers of medical ethics, and hospital ethics committees.3"10 However, the study of moral development in healthcare providers has been hampered because collecting the necessary data from healthcare workers has been labor intensive and extremely time consuming. More efficient methods are needed. Increased interest in the relationship of moral reasoning and moral orientation has resulted in projects that assess both in the same research subjects.11"13 Traditionally, however, research in moral reasoning and moral orientation has typically required approximately 1-1 \ hours for the moral reasoning interview and another 1-15 hours for the moral orientation interview for each research subject. Thus, projects interested in both moral reasoning and moral orientation would require 2-3 hours of interview for each research subject. Because such a time commitment seemed too much to ask of many research subjects, especially healthcare providers, attention has been directed toward combining the interview instruments so that a single interview could simultaneously assess both moral reasoning and moral orientation in no more than \-\\ hours. Over the last 25 years, the theoretical work of Kohlberg in cognitive moral development has led to hundreds of studies around the world assessing the moral judgment or moral reasoning of a great variety of people in a wide range of circumstances, from public schools to prisons.14 His research led to the establishment of his well-known stage theory of three levels and six stages of moral development, which has been described and summarized elsewhere.15'16 Various criticisms of the theory, particularly by Gilligan, later led Kohlberg to refer to justice reasoning rather than moral reasoning because he acknowledged that the concept of justice was the foundation for his moral theory. Nevertheless, in the field of moral development theory the notion of moral reasoning is still the prevalently This project was funded in part by grants from the United Ministries in Education, the United Church Board for Homeland Ministries, and the American Medical Association's Division of Medical Education Research and Information whose generous support is gratefully acknowledged and appreciated. We also acknowledge Professor Jerome Trzeciakowski for his assistance with the statistical analysis. Cambridge Quarterly of Healthcare Ethics (1992), 4, 371-376. Printed in the USA.
Copyright © 1992 Cambridge University Press 0963-1801/92 $5.00 + .00
371
Donnie J. Self and Joy D. Skeel
used concept, with the assumption of justice as the basis of morality. The work of Gilligan and Noddings has presented a serious challenge to that assumption with their claim that care is the basis of morality, especially for females.17'18 Although subsequent instruments based on Kohlberg theory have been developed, most notably the Defining Issues Test (DIT) of Rest19 and the Socio-moral Reflection Measure (SRM) of Gibbs,20 the most accurate instrument of assessment of moral reasoning has been the original oral Moral Judgment Interview (MJI) of Kohlberg.21 In her work, Gilligan has pointed out that the way people choose to frame a moral problem or the interpretation they place on the context in which it is embedded creates an organizing framework for moral decisions that is equally as important as the logic of the reasoning and ultimately influences the solution chosen and the way it is understood as a moral issue. The two organizing frameworks she has identified have been that of an orientation of justice and an orientation of care. The orientation of justice characterizes relationships in terms of equality and inequality, whereas the orientation of care characterizes relationships in terms of attachment and detachment. Similarly, the justice orientation links vulnerability to oppression and is mainly concerned with issues of fairness, rights, standards, and principles, whereas the care orientation links vulnerability to abandonment and is mainly concerned with issues of connectedness, attachment, and the effects an act will have upon relationships. Although the instrument for assessment of moral orientation was initially constructed from research in women's psychological development, it has been evolving in recent years, and various versions of the main real-life dilemma interview have been employed in a series of studies assessing moral orientation in both males and females.22'23 Description of the Instrument In this project, an interview instrument was developed called the Moral Reasoning/Orientation Interview (MROI) by combining parts of the standard Kohlberg MJI and parts of the Gilligan Real-Life Moral Conflict and Choice Interview into a single instrument. The instrument was originally developed for a project involving highly educated adult research subjects, namely philosophers and theologians who teach medical ethics and who would reasonably be expected to exhibit high stage moral reasoning. Therefore at Kohlberg's suggestion, one dilemma, the life dilemma, was taken from Form A and Form B of the standard MJI and combined with the law dilemma from Form B. Parts of the Gilligan interview focusing on real-life dilemmas were incorporated and other parts focusing on how one sees oneself were omitted. Parts of the Johnson interview using Aesop's fables were included as a backup for assessing moral orientation in case the real-life dilemmas were insufficient on some occasions for determining moral orientation.24 However, this segment of the interview has not been necessary, thus rendering the prospect of reducing the time of administration even further. Furthermore, a cross check to determine the accuracy and validity of assessing moral orientation by the fable method compared with the real-life dilemma method has not yet been carried out. A copy of the MROI can be obtained by contacting the authors. Results Once the instrument was completed, the MROI was tested to see if it would indeed provide moral reasoning stages and moral orientation in a single interview 372
Healthcare Ethics Research
Table 1. Agreement of Subject Moral Reasoning Stage Scores as Analyzed by Two Different Scorers
n Project 1 Project 2a a
Exact agreement
Agreement within 1/3 of a stage
67% 75%
100% 100%
Only eight transcripts were double scored.
of no more than \\ hours. On two occasions, a pilot project of 3 interviews and a larger project of 16 interviews, the MROI has functioned satisfactorily. Colleagues of Kohlberg and Gilligan who had extensive experience in analyzing these types of transcripts found the instrument provided the data necessary for both moral reasoning stages and moral orientation. The interviews ranged from 1 hour to \\ hours, averaging l | hours, including the use of the Aesop's fable method in addition to the real-life dilemma. In the pilot project, the three transcripts of the interviews were analyzed independently by two experienced scorers (not the authors) for moral reasoning stages based on the 1987 published scoring manual.25 In 67% of the cases the scores were in exact agreement and in 100% of the cases the scores were within 1/3 of a stage of each other, which is a generally acceptable range of variation (Table 1). Similarly, the transcripts of the interviews were analyzed independently by two experienced readers for moral orientation (not the authors nor the scorers for stages) based on the 1987 prepublication reading guide.26 In this case, the results of the readers' analyses were in complete agreement for presence of an orientation of justice or care in 67% of the cases and were reconcilable between the two readers in 100% of the cases (Table 2). However, analysis for predominance of an orientation brought complete agreement in only 33.33% of the cases, although reconciliation of predominance was 100% between the two readers. There was complete agreement on alignment of orientation (i.e., articulation of both orientations by the interviewee with endorsement of one and rejection of the other) in 100% of the cases.
Table 2. Comparison of Subject Moral Orientation Analyses by Two Different Readers Orientation Orientation Orientation presence predominance alignment Complete Reconcilable Complete Reconcilable Complete Reconcilable agreement interpretations agreement interpretations agreement interpretations Project 1 Project 2
66.67% 81.25%
100% 93.75%
33.33% 62.50%
100% 81.25%
100% 68.75%
87.50%
373
Bonnie ]. Self and Joy D. Skeel
In the larger project of 16 interviews, the two experienced scorers of moral stage reasoning obtained exact agreement in 75% of the cases and were within 1/3 of a stage of each other in 100% of the first half of the cases. In light of the 100% agreement from the pilot project and the first half of the cases in the larger project, the last half of the cases in the larger project were not double scored. In the analysis for moral orientation, however, both readers analyzed all 16 transcripts. The agreement on presence of orientation was much closer, with complete agreement in 81.25% of the cases and reconcilable interpretations in 93.75% of the cases. In the other 6.25% of the cases, the two readers just agreed to disagree because neither one could present evidence from the transcripts that was persuasive to the other. Analysis for predominance of orientation was likewise much closer, with complete agreement in 62.50% of the cases and reconciliation in 81.25% of the cases. There was complete agreement on alignment of orientation in 68.75% of the cases, with reconciliation in 87.50% of the cases. Although neither the complete Form A or Form B was incorporated into the MROI, there seemed to be no reason to doubt the adequacy of determining moral stages from the MROI. This issue, however, was tested by having a series of 10 subjects take the standard Form A of the MJI and the MROI for comparison. When scored separately by the same scorer (not the authors), no significant differences (p < .5975) in the scores were found between the two different forms for assessing moral reasoning (Table 3).
Table 3. Comparison of MJI and MROI for Assessing Moral Reasoning Subject IDa 1A IB 2A 2B 3A 3B 4A 4B 5A 5B 6A 6B 7A 7B 8A 8B 9A 9B 10A 10B a
Stage score
WAS scoreb
4.5 4.5 4.5 4.5 4.0 3.5 4.0 4.0 3.5 3.5 4.0 4.0 4.5 4.5 4.0 3.5 4.0 4.0 4.0 4.0
450 436 457 464 379 371 400 394 360 329 396 380 475 459 405 372 400 395 413 387
A = Moral Judgement Interview (MJI); B = Moral Reasoning/Orientation Interview (MROI). b WAS (Weighted Average Score) is a continuous score that ranges from a possible low of 100 to a maximum of 500 and is correlated to the stages in Kohlberg's cognitive moral development theory for determining the stage score.
374
Healthcare Ethics Research
Discussion The data generated by the MROI in this project concerning moral reasoning stages fit well with those of other studies regarding the ability to generate reliable, predictable, and reproducible stages from oral interviews with subjects. However, the data generated by the MROI concerning moral orientation may indicate the evolving nature of the system of analysis of moral orientation and the preliminary stage of the reading guide or may simply reflect the state of the art of determining moral orientation, which has not yet had the advantage of going through the 25 years of revision and refinement that the scoring manual and system of assessing moral stages of reasoning have experienced. Assessing both moral reasoning stage and moral orientation in a single interview poses a problem, especially for the assessment of moral orientation. Because the MROI was constructed from part of the Kohlberg interview format and part of the Gilligan interview format, the introduction of the Kohlberg questions first may bias the subject toward a justice orientation, whereas the introduction of the Gilligan questions first may bias the subject toward a care orientation. This influence could be determined by alternating which questions are introduced first and comparing the results. A study is underway to determine the existence and extent of this potential bias problem. Conclusion An instrument has been developed that will adequately provide data and will greatly facilitate studies of the relationship of moral reasoning to moral orientation and studies of each factor alone for correlation with other characteristics. With the MROI, studies that could correlate the moral orientation obtained by the Aesop fables (a technique previously used only with children) with the moral orientation obtained by the real-life dilemmas can more easily be conducted. Because the Aesop fable technique is much simpler and quicker and is less threatening, it may become an interesting refinement in the process of assessment of moral orientation.
Notes 1. Gilligan C. In a Different Voice: Psychological Theory and Women's Development. Cambridge, Massachusetts: Harvard University Press, 1982. 2. Colby A, Kohlberg L. The Measurement of Moral Judgment: Vol. I, Theoretical Foundations and Research Validation. New York: Cambridge University Press, 1987. 3. Sheehan TJ, Husted SDR, Candee D, et al. Moral judgment as a predictor of clinical performance. Evaluation and the Health Professions 1980;3:393-404. 4. Crishom P. Measuring moral judgment in nursing dilemmas. Nursing Research 1981;30:104-10. 5. Bebeau MJ, Rest JR, Yamoor CM. Measuring dental students' ethical sensitivity. Journal of Dental Education 1985; 49:225-35. 6. Self DJ, Safford SK, Shelton GC. Comparison of the general moral reasoning of small animal veterinarians vs. large animal veterinarians. The Journal of the American Veterinary Medical Association 1988;193:1509-12. 7. Self DJ, Jecker NS, Baldwin DC Jr, et al. Moral orientations of justice and care among veterinarians entering veterinary practice. The Journal of the American Veterinary Medical Association 1991;199:569-73. 8. Dobrin A. Ethical judgments of male and female social workers. Social Work 1989;34:451-5.
375
Donnie J. Self and Joy D. Skeel 9. Self DJr Skeel JD. A study of the foundations of ethical decision making of clinical medical ethicists. Theoretical Medicine 1991; 12:117-27. 10. Dugan DO. Masculine and feminine voices: making ethical decisions in the care of the dying. The Journal of Medical Humanities and Bioethics 1987;8:129-40. 11. Walker L, de Vries B, Trevethan S. Moral stages and moral orientations in real-life and hypothetical dilemmas. Child Development 1987;58:842-58. 12. Bebeau M, Brabeck M. Integrating care and justice issues in professional moral education: a gender perspective. The Journal of Moral Education 1987; 16:189-203. 13. Self DJ, Skeel ]D, Jecker NS. The moral development of clinical medical ethicists: the influence of philosophical vs. theological education. Academic Medicine (submitted). 14. Snarey JR. Cross-cultural universality of social-moral development: a critical review of kohlbergian research. Psychological Bulletin 1985;97:202-32. 15. Kohlberg L. Moral stages and moralization: the cognitive developmental approach. In: Lickona T, ed. Moral Development and Behavior: Theory, Research, and Social Issues. New York: Holt, Rinehart and Winston, 1976:31-53. 16. Self DJ, Wolinsky FD, Baldwin DC Jr. The effect of teaching medical ethics on medical students' moral reasoning. Academic Medicine 1989;64:772-6. 17. Gilligan C, Attanucci J. Two moral orientations: gender differences and similarities. Merrill-Palmer Quarterly 1988; 33:223-37. 18. Noddings N. Caring: A Feminine Approach to Ethics and Moral Education. Los Angeles: University of California Press, 1984. 19. Rest JR. Development in Judging Moral Issues. Minneapolis: University of Minnesota Press, 1979. 20. Gibbs JC, Widaman KR Social Intelligence: Measuring the Development of Sociomoral Reflection. Englewood Cliffs, NJ: Prentice-Hall, 1982. 21. Kohlberg L. Essays on Moral Development: Vol. II. The Psychology of Moral Development. New York: Harper and Row, 1984. 22. Lyons N. Two perspectives: on self, relationships, and morality. Harvard Educational Review 1983;53:125-45. 23. Gilligan C, Johnston D, Miller B. Moral Voice, Adolescent Development, and Secondary Education: A Study at the Green River School. Cambridge, Massachusetts: Center for the Study of Gender, Education, and Human Development, Harvard University, Monograph #3, 1988. 24. Johnston K. Adolescents' solutions to dilemmas in fables: two moral orientations —two problem solving strategies. In: Gilligan C, Ward JV, Taylor JM, eds. Mapping the Moral Domain. Cambridge, Massachusetts: Center for the Study of Gender, Education and Human Development, Harvard University/l985:49-71. 25. Colby A, Kohlberg L. The Measurement of Moral Judgment: Vol. II, Standard Issue Scoring Manual. New York: Cambridge University Press, 1987. 26. Brown L, Argyris D, Attanucci J, et al. A Guide to Reading Narratives of Moral Conflict and Choice for Self and Moral Voice. Cambridge, Massachusetts: Center for the Study of Gender, Education, and Human Development, Harvard Graduate School of Education, Monograph #1, 1987.
376
