Social Science & Medicine 345 (2024) 116662

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Social Science & Medicine

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Evaluating the use of casuistry during moral case deliberation in the ICU: A
multiple qualitative case study
Niek Kok a, *, Cornelia Hoedemaekers b, Malaika Fuchs c, Hans van der Hoeven b,
Marieke Zegers b, Jelle van Gurp a
a
Radboud University Medical Center, Department of IQ Health, Kapittelweg 54, 6525, EP, Nijmegen, Netherlands
b
Radboud University Medical Center, Department of Intensive Care, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, Netherlands
c
Canisius Wilhelmina Hospital, Department of Intensive Care, Weg Door Jonkerbos 100, 6532, SZ, Nijmegen, Netherlands

A R T I C L E I N F O A B S T R A C T

Handling Editor: Alexandra Brewis Intensive care unit (ICU) professionals engage in ethical decision making under conditions of high stakes, great
uncertainty, time-sensitivity and frequent irreversibility of action. Casuistry is a way by which actionable
Keywords: knowledge is obtained through comparing a patient case to previous cases from experience in clinical practice.
Casuistry However, within the field of study as well as in practice, evidence-based medicine is the dominant epistemic
Clinical decision-making
framework. This multiple case study evaluated the use of casuistic reasoning by intensive care unit (ICU) pro­
Discourse analysis
fessionals during moral case deliberation. It took place in two Dutch hospitals between June 2020 and June
Evidence-based medicine
Intensive care 2022. Twentyfive moral case deliberations from ICU practice were recorded and analyzed using discourse
Moral case deliberation analysis. Additionally, 47 interviews were held with ICU professionals who participated in these deliberations,
The Netherlands analyzed using thematic analysis. We found that ICU professionals made considerable use of case comparisons
when discussing continuation, withdrawal or limitation. Analogies played a role in justifying or complicating
moral judgements, and also played a role in addressing moral distress. The language of case-based arguments is
most often not overtly normative. Rather, the data shows that casuistic reasoning deals with the medical, ethical
and contextual elements of decisions in an integrated manner. Facilitators of MCD have an essential role in
(supporting ICU professionals in) scrutinizing casuistic arguments. The data shows that during MCD, actual
reasoning often deviated from principle- and rule-based reasoning which ICU professionals preferred themselves.
Evidence-based arguments often gained the character of analogical arguments, especially when a patient-at-hand
was seen as highly unique from the average patients in the literature. Casuistic arguments disguised as evidence-
based arguments may therefore provide ICU professionals with a false sense of certainty. Within education, we
should strive to train clinicians and ethics facilitators so that they can recognize and evaluate casuistic
arguments.

1. Introduction actionable knowledge is through casuistic, or case-based, reasoning

(Zussman, 1992). Jonsen and Toulmin have defined casuistry as
On the intensive care unit (ICU), ICU professionals frequently engage reasoning
in ethical decision making on withdrawing, continuing or limiting
“based on paradigms and analogies, leading to the formulation of
treatment for a patient. They do so in high stakes situations character­
expert opinions about the existence and stringency of particular
ized by uncertainty, time-sensitivity, and frequent irreversibility of ac­
moral obligations, framed in terms of rules or maxims that are gen­
tion (Connors and Siner, 2015; Erving et al., 2018; Oerlemans et al.,
eral but not universal or invariable, since they hold good with cer­
2015; Wubben et al., 2021). In these circumstances, ICU professionals
tainty only in the typical conditions of the agent and circumstances
value moral and clinical knowledge that helps to determine what would
of action” (Jonsen and Toulmin, 1989, 257).
be the next best thing to do for a patient (Khushf, 2013; Stonington,
2020). One approach through which ICU professionals obtain such Casuistry generates moral imperatives for action through an analogy

* Corresponding author.
E-mail address: niek.kok@radboudumc.nl (N. Kok).

https://doi.org/10.1016/j.socscimed.2024.116662
Received 6 October 2023; Received in revised form 27 December 2023; Accepted 5 February 2024
Available online 12 February 2024
0277-9536/© 2024 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
N. Kok et al.
between the patient-at-hand and a paradigmatic case. The latter is an
exemplary case in which an ethical principle typically applies (Arras,
1991; Bleyer, 2020; Jonsen and Toulmin, 1989). Casuistic reasoning on
the ICU is, however, understudied. Instead, principle-based decision
making and evidence-based medicine (EBM), both of which contrast
with casuistry, are often taken to be the ideal action-guiding approach in
clinical practice (Bingeman, 2016; Hanemayer, 2016; Thompson, 2007;
Van Baalen and Boon, 2015). EBM aims to reduce clinical and moral
uncertainty by deriving guidelines and rules from studying patient
populations (Greckhamer and Cilesiz, 2014; Wieringa et al., 2021).
Reasoning in EBM proceeds in a data-driven and quasi-deductive
manner, with an apparent preference for rule-based reasoning, akin to
reasoning from principles. Research studies are said to demonstrate
conclusions such as ‘A reduces the risk of B’. Clinicians are then to use
these empirically derived principles to determine the best course of
action for an individual patient. While EBM is seen as the predominant
epistemic framework within clinical practice and medical education
(Hanemayer, 2016), some authors have critically assessed whether as an
epistemological model it is able to accommodate how reasoning in
clinical practice naturally takes place (Greckhamer and Cilesiz, 2014;
Van Baalen and Boon, 2015). The same argument has been raised
against principle-based ethics (Jonsen and Toulmin, 1989; Urban
Walker, 2007). However, EBM is currently seen as the preferred model
for reasoning in practice, and much research is also focused on evalu­
ating how EBM can best be stimulated, learned or educated. In the
meanwhile, casuistic reasoning in clinical practice remains under­
studied (Braunack-Mayer, 2001; Ubachs-Moust et al., 2008; Van Baalen
and Boon, 2015).
The use of casuistry is not limited to moral judgement. Within this
study, we however specifically focus on the use of casuistry during moral
case deliberation (MCD), a team-based moral dialogue about a moral
problem from practice where a facilitator structures the dialogue using
one of several accepted conversation methods (Haan et al., 2018). MCDs
are oftentimes organized in response to highly complex ethical cases,
and are considered a forum where ICU professionals have to explicate
their reasons and arguments (Haan et al., 2018; Heidenreich et al., 2018;
Steinkamp and Gordijn, 2003), making it ideal for assessing the use of
casuistic reasoning.
In order to empirically and normatively assess the use of casuistry
during MCD on the ICU, this study poses the following research
questions:
a. How do ICU professionals engage in casuistry during groupwise
discussion of ethical cases?
b. What is the function of casuistic reasoning in the ICU?
c. What are the implications of using casuistry during the moral
reasoning processes on the ICU?
2. Materials and methods
2.1. Design
This study was designed as a prospective multiple case study of
casuistic reasoning during MCD on the ICU. The study took place be­
tween June 2020 and June 2022 in adult and pediatric ICUs of a uni­
versity medical center and a teaching hospital, both located in the
Netherlands.
A case study is an in-depth empirical inquiry into a single phenom­
enon within its naturalistic context (Yin, 2014, 16). Within this study,
each “case” corresponded to a single MCD in the ICU. Case studies may
illuminate gaps between theory and practice in research areas where
there are a lot of variables at play (Crowe et al., 2011; Yin, 2014). The
case study design allowed for a comparison of how casuistry is described
theoretically and versus it’s use during MCDs in actual ICU practice. By
combining ethical theory and an ethnography based on naturally spoken
language, this multiple case study stands at the intersection between
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Social Science & Medicine 345 (2024) 116662
conceptual and empirical research (Davies et al., 2015; Hoffmaster,
1992; Urban Walker, 2007).
2.2. Ethical approval
Ethical approval for this study was sought from the regional ethics
committee of the Region Arnhem-Nijmegen (registration number:
2018–4346), which deemed the study exempt from further screening in
April 2020. Study procedures were followed in accordance with the
ethical standards of the regional ethics committee Arnhem-Nijmegen,
Dutch law, and the Helsinki Declaration of 1975.
2.3. Case selection
In selecting cases, we aimed for relative homogeneity of the sort of
moral issue which ICU professionals discussed during MCD (Kok et al.,
2022). MCDs were selected as cases according to these criteria:
- the MCD took place between June 2020 and June 2022;
- it addressed a decision of continuation, withdrawal or limitation of
ICU treatment;
- it addressed a specific ICU patient.
Patient-bound MCDs were selected because in such MCDs ICU pro­
fessionals generally need to identify the patient’s preferences and per­
spectives on life, assess the patient’s clinical situation and corresponding
evidence, provide a moral diagnosis, set goals and make a decision, all of
which are potential triggers for casuistic reasoning (Steinkamp and
Gordijn, 2003).
2.4. Data collection
All MCDs taking place in the ICU were observed and audio-recorded.
Observations helped the researchers to form initial thoughts about the
use of casuistry. The recordings of MCDs which fulfilled the selection
criteria were transcribed. Additionally, in a number of cases, semi-
structured interviews were conducted with ICU professionals who
participated in MCD to further contextualize the case, to assess how
professionals evaluated the use of casuistry and whether the researchers’
initial thoughts on the use of casuistry made sense to them (for the
interview guide, see Supplement A). Interviews were conducted by a
trained interviewer, audio-recorded and transcribed.
Study participants were informed about the study before data
collection. MCD participants verbally consented to audio-recording.
Interviewees provided written informed consent. When citing ICU pro­
fessionals who participated in MCD, the participant’s professional role
and the case number are given (for instance: case 1 is “C1”). Whenever
an ICU professional from the interview data is cited, the participants
unique code (Supplement 1) is provided.
2.5. Data analysis
Data analysis proceeded in three steps. First, a within-case analysis
was conducted, meaning that all data pertaining to one case (e.g.,
transcript, interviews) was analyzed and the research questions were
answered for that case (Fig. 1). This process was repeated for all cases.
Thereafter, a cross-case synthesis was conducted of all cases which were
part of a higher-order unit of analysis (Yin, 2014). Higher-order units of
analysis were either a time series of MCDs about the same patient and/or
all MCDs that took place in the same ICU – for instance, the pediatric
ICU. Finally, the results of the cross-case synthesis are presented.
All data was managed and analyzed in CAQDAS ATLAS. ti 22.0.11
(ATLAS.ti Scientific Software Development GmbH, Berlin, Germany).
Transcripts of MCD were analyzed using discourse analysis. The
discourse analysis subsequently informed thematic analysis of interview
transcripts.
N. Kok et al. Social Science & Medicine 345 (2024) 116662

3. Results

3.1. Case characteristics

Fig. 1. Within-case data collection and analysis.
2.5.1. Discourse analysis
Discourse can be defined as “language in use in social settings”
(Fairclough, 2005; Greckhamer and Cilesiz, 2014; Hodges, 2008).
Discourse analysis focuses on how people in specific settings use lan­
guage to construct and make sense of social realities, and share a com­
mon way of speaking about things (Little et al., 2003). Among several
approaches of discourse analysis (cf. Hodges, 2008), critical discourse
analysis is particularly concerned with how people use language stra­
tegically to persuade others into adopting a particular viewpoint as
“true” (Hodges, 2008).
Within this study, critical discourse analysis focused on casuistry as a
form of moral reasoning. Analogical reasoning is a central element of
casuistry. This meant that the analysis of transcripts focused on the
content, wording, and grammar in instances where ICU professionals
engaged in casuistic moral reasoning, and traced how comparisons and
analogies – which are elements of casuistic reasoning – impacted the
structure and course of the MCD.
In total 55 MCDs took place between June 2020 and June 2022, of
which 25 MCDs fulfilled the selection criteria and were therefore
included as cases (Fig. 2): eleven cases from the adult ICUs in the Uni­
versity Medical Center (C1 to C11), five cases from the ICU within the
teaching hospital (C12 to C16), and nine cases from the pediatric ICU
(C17 to C25).
A transcript of MCD was obtained for 23 of the 25 cases. Data on the
two cases with missing transcripts was collected through interviews with
ICU professionals who participated in these MCDs. A total of 47 in­
terviews with 40 unique individuals were conducted in a total of 14
cases. Supplement 1 provides an overview of the interview participants
and the cases upon which they were asked to reflect. Sixteen interview
participants (40%) were ICU nurses, eight interview participants (20%)
were staff physicians working on an adult ICU, five interview partici­
pants (12.5%) were staff physicians working on the pediatric ICU, four
interview participants (10%) were residents either working on the adult
or pediatric ICU, and two interview participants (5%) were fellows.
Lastly, interviews were conducted with one general practitioner, one
pulmonologist, one oncologist, one quality officer and one spiritual
counselor.
The results section is structured according to the three research
questions introduced above. In response to the first question, we provide
a description of the manner in which ICU professionals engage in

2.5.2. Thematic analysis

Subsequently, a thematic analysis was conducted on the interview
transcripts. Thematic analysis identifies patterns or themes within
qualitative data (cf. Braun and Clarke, 2006). Thematic analysis was
highly informed by the preceding discourse analysis which focused on
aspects of casuistry – i.e. analogical reasoning – within the transcripts
and theory on casuistry itself. Thematic coding therefore focused on
deepening understanding of the results of the critical discourse analysis,
or otherwise further contextualization of the case with regards to the use
of casuistry by ICU professionals. Occasionally, the thematic analysis
iteratively informed the discourse analysis (Fig. 1).

2.6. Interpretation bias and triangulation

A discourse consists first of what is literally said by language users

and second of what is said by extension. The latter must inevitably be
obtained through a process of interpretation. This study attempted to
minimize bias arising from such interpretation through triangulation
(Flick, 2018; Yin, 2014). Triangulation is the combination of different
theories, data, methodologies, and analysts within research, with the
goal of raising the analysis above biases that stem from using a single
theory, data, methodology or investigator (Flick, 2018). Data triangu­
lation was achieved by collecting the two aforementioned types of data.
Methodological triangulation was achieved by integrating the results of
discourse analysis and thematic analysis. Investigator triangulation was
aimed for by having the data evaluated by three coders (NK, JvG, and a
supporting researcher).

Fig. 2. Multiple case study design and cross-case syntheses.

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N. Kok et al.
casuistry during MCD. We highlight that the moral discourse during
MCD is characterized by the use of repeating case analogies. We also
show how facilitators address casuistry during MCD. In response to the
second question, three functions of casuistry are identified: casuistic
arguments are used to justify or deflect courses of action, to introduce
complexity in the discussion of a clinical case, or to address moral
distress. Third, the implications of casuistry for the moral reasoning
process are assessed.
3.2. Question 1: how do ICU professionals engage in casuistry during
moral case deliberation?
ICU professionals made considerable use of case comparisons when
discussing continuation, withdrawal or limitation. Comparisons were
made between a patient-at-hand and similar other patients, greater
samples of patient cases from the medical literature, expected disease
patterns, hypothetical case examples and/or non-clinical cases or situ­
ations. A patient-at-hand was often described as a typical, standard, rare
or even marginal case, e.g. a patient could be described as a “standard
COVID-19 story” (ICU nurse, C13). Moral case deliberations differed
with regard to the frequency by which such comparisons were
introduced.
As a rule, the moral reasoning process became thoroughly casuistic
after a facilitator or a participant introduced an initial, morally signifi­
cant case comparison. The introduction of such a comparison led other
participants to further explore the similarities or contrasts between the
two cases, consequently deepening the analogical reasoning process.
C7 is an example, where ICU professionals opted to withdraw
treatment for a homeless psychiatric patient with spinal cord injury
(SCI). The facilitator contrasted the homeless spinal case injury patient
with a hypothetical case: “Would our judgement in this case have been
different if this would have been – say – a forty year old loving father of
three children?” (Facilitator, C7). This triggered several ICU nurses to
cite similar, settled patient cases in which the team opted to continue
treatment, leading up to a remark of an ICU nurse:
“Usually – based on what we know from spinal cord injury patients –
most patients want to discontinue treatment. Those patients do not
want to live with their disability. But then the medical team says:
let’s wait for a few weeks, the patient’s preferences will change. […]
I really want to understand – what is the difference with this case?”
(ICU nurse, C7).
The ICU nurse further asked: “what [aspects of this case] determine
our judgement here? I remember a lot of similar cases […] where we
continued treatment” (ICU nurse, C7). The team discussed the aspects
about which the nurse asked: the patient’s age, his social economic
status, his social supportive network and his capacity to rehabilitate.
One physician argued that, in spite of the way in which previous cases
were settled, withdrawal of treatment for this particular patient was
justified because of the patient’s psychiatric condition which prohibited
adaptation to the disability. In reaction, other ICU nurses cited past cases
of SCI patients which also had psychiatric conditions and for whom
treatment was continued. However, these comparable cases where
deemed different by a physical therapist, who cited literature on the
importance of a social supportive network for these types of patients.
Such a network was present in the cases cited by the ICU nurses, but was
not present in the case-at-hand. Overall, the initial remarks made by the
facilitator and the ICU nurse led to a thoroughly casuistic debate among
ICU professionals.
Across the MCDs within the dataset, ICU professionals repeatedly
invoked what can be considered paradigm cases. We provide three
common examples. First, there was a past, alcoholic patient known by
many ICU professionals and referred to in C5, C9, and C10. This patient
was repeatedly invoked as a case that supposedly settled the question of
whether to continue or withdraw treatment for patients with an un­
healthy lifestyle, solely on the basis of their unhealthy lifestyle.
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Social Science & Medicine 345 (2024) 116662
A second influential paradigm case was the ‘standard’ SCI patient.
This paradigm was invoked in the case mentioned above (C7), but also in
C4, C6, and C15. The SCI patient paradigm justified treatment contin­
uation for patients who expressed the wish to stop treatment in the early
phase of a newly acquired disability, but of whom it was expected that
they would adapt to this disability in the long-term. The SCI paradigm
was also extended to patients with traumatic brain injury (TBI) (C6) or
severe neurological damage (C15). As an analogy, it seems to solve the
moral conflict between respecting a patient’s autonomy and the prin­
ciple of beneficence by proposing to override a patient’s expressed
preferences on the short-term, in cases where it was not known what the
patient’s preferences would be. For instance, the analogy helped to infer
that in the long-term, a TBI patient would prefer treatment to continue,
analogous to standard spinal cord injury patients.
A third paradigm case was a patient with end-stage cancer. ICU
professionals typically introduced this analogy when they argued in
favor of withdrawing treatment and preparing patients for end-of-life
care (e.g. in C8, C9, C10, C13, and C20). Again, even when the
patient-at-hand did not suffer from cancer, this analogy was still brought
up. The analogy was invoked for patients whenever their condition was
deemed progressive, irreversible, or terminal. This included patients
with severe alcoholism, morbid obesity, schizophrenia, and advanced
vascular diseases. This analogy achieved the reverse of the SCI patient
analogy, since it proposes to discontinue treatment for a patient who
supposedly wants treatment to continue. The premise of the analogy
seems to be that it would be better for a patient to adjust to the idea that
his/her disease is a terminal one, and that the patient would benefit most
from palliative care.
The data is rich with examples where ICU professionals mentioned
patients from their shared experience that illustrated their moral claims,
but where it was unclear whether that patient constituted a paradigm
case. Much additional discourse within the data implied a background
moral taxonomy, but no explicit case comparison was made. For
instance, in C5, ICU professionals addressed a patient-at-hand who
adhered to an unhealthy lifestyle and who appeared to be fairly
apathetic about this. An intensivist remarked that in order to justify
continuation of treatment in such a case, you would need a “motivated
patient” (intensivist, C5). This statement had taxonomical effect: the
intensivist’s suggestion would be that it matters, morally, whether a
patient is motivated to change his/her lifestyle or not. If a patient cannot
be motivated to change lifestyle, then there would be no prospect for
improvement. In another example the ICU team considered withdrawing
treatment for a pediatric patient “who smiles back at you” (intensivist,
C23). One intensivist recognized that while this patient did not have a
good prognosis based on the evidence, it would nevertheless be immoral
to abruptly withdraw treatment for a patient that is awake, smiles and
occasionally seems happy. Highlighting this feature of the patient im­
plies that if this were not a wake and smiling child, withdrawing treat­
ment would have been a more acceptable course of action. Statements
like these taxonomically divide patients into seemingly morally relevant
categories.
3.2.1. The role of facilitators in assisting or obstructing casuistic argument
The data shows that facilitators had a central role in either stimu­
lating, obstructing or educating ethical reasoning using casuistry
(Table 1). Sometimes, facilitators explicitly stimulated casuistic argu­
ments by asking participants to come up with case-comparisons or
counterfactuals (see for instance Examples 1.1 and 1.2). Facilitators
sometimes recognized case-comparisons, allowing them to explicitly ask
an ICU professional to explain why some case was similar to the patient-
at-hand. However, while facilitators acknowledged that it is “common
practice to compare patients” (Example 1.3), case comparisons also
distracted the ICU professionals from the patient-at-hand, sometimes
leading facilitators to cut analogical reasoning short so as to keep a
focused deliberation. In this study, MCDs lasted, in principle, no longer
than an hour. As indicated by the facilitator in Example 1.4 as well as by
N. Kok et al. Social Science & Medicine 345 (2024) 116662

Table 1 Table 2
Examples of how facilitators stimulate, obstruct or educate from casuistry. Examples of functions and purposes of casuistic reasoning in the ICU.
Function Example Citation Function Example Citation

Stimulative 1.1 A facilitator commences the moral dialogue by asking: Justifying or 2.1 “Almost everyone says that they do not want to
“Would our judgement in this case have been different if deflecting action become a ‘vegetable’. But people do not really
this would have been – say – a forty year old loving father know what this actually means. We know from
of three children?” (Facilitator, C7). the literature on […] spinal cord injury patients,
1.2 A facilitator actively calls on ICU professionals to that they want to die in the first phase of
introduce similar cases: “Right now, we can only come to treatment. All people with a high cervical spinal
a judgement on the basis of several comparable children cord injury want to die. But if you ask them two
who have struggled with a disease like this” (Facilitator, or three months later, their preferences change.
C19). And this is the reason why as intensivists, we do
Obstructive 1.3 “I understand it is common practice to compare patients, not withdraw treatment in the first two months
but I have to keep the discussion focused on this patient” – because we know people need time to adapt”
(Facilitator, C10). (intensivist, C15).
1.4 A non-ICU professional compares a patient-at-hand with 2.2 “[This patient’s condition] is somewhat
a previous patient to illustrate that across cases, the comparable with a cancer patient who fights for
conversation on withdrawing or continuing treatment his life but does not get better. It is a terminal
takes place too late. The facilitator reacts by stating: “I disease. […] This means that at some point you
think that is a good reflection, but – given the time – it is a will have to offer the patient therapy with the
bit too far removed from our current discussion” goal of making him accept that this will be the
(Facilitator, C23). end” (intensivist, C10).
Educative 1.5 A facilitator concludes a moral case deliberation by 2.3 “It is very hard to say: let’s stop treatment [for
noting: “I think it would be useful to – if there are any this patient], simply because we feel it will not
similar moral problems of this kind – compare these. […] work out. […]. Recently, we had another
What makes our judgment? When and why does [patient] with severe neurotrauma. We had
judgment differ? How do different patients compare to thrown in the towel a hundred times during
each other and the decisions we make across cases?” treatment, but still, [the other patient]
(Facilitator, C3) ultimately woke up again” (intensivist, C6).
1.6 A facilitator concludes a moral case deliberation by Ambiguating the 2.4 “If you search the literature asking what the
noting how the case is illustrative of a larger problem: case prognosis of these patients is, then you find that
“The case is like a keyhole through which we peer at a most studies predict a 12-month mortality of
larger problem” (Facilitator, C12). thirty percent. […] but [this patient] does not
wholly fit into the profile, because intubated
patients were excluded [and this patient was
a facilitator during an interview, time always is a consideration when intubated]” (intensivist, C5).
2.5 “Especially with those rare, syndromic children
deciding which statements need further exploration and which state­
who have more disorders on several systems,
ments are left unexplored (SC1, interview). The aim is to come up with one and one are not always two. Sometimes you
actionable conclusions in a patient-case, and the facilitator has to ensure just need time. And [in those situations] maybe
that the MCD lasts no longer than needed. we should try to address that there is a feeling in
Facilitators do, at the same time, sometimes emphasize that con­ the team: this treatment is no longer
proportional, but also the feeling in another part
clusions in one patient-case may have consequences for how other pa­
of the team: we need time and let’s all go along
tient cases should be perceived. The way in which casuistry operates – with it” (intensivist, C21).
by comparison with and generalization from paradigm cases – is then Addressing moral 2.6 A non-ICU physician reacts to an ICU nurse who
used as a form of education. Examples 1.5 and 1.6 illustrate how fa­ distress describes enormous difficulties with a severely
cilitators use the conclusions of MCD as a form of casuistic education. addicted patient: “I completely understand that
you experience difficulties [with working
Such statements may help ICU professionals in considering the broader towards a goal for a patient who does not adhere
implications of moral judgement in particular cases. to treatment]. However, if I look at our entire
population, and then especially at the people
who are most severely addicted to drugs, then
3.3. Question 2: what is the function of casuistic reasoning in the ICU? this applies to all of them. […] We do not really
make long-term care plans for these patients”
From the data, it is possible to identify at least three functions of (non-ICU physician, C1).
casuistry: casuistic arguments were used to justify or deflect courses of 2.7 An ICU nurse shows great concern for a
traumatic brain injury patient’s prognosis based
action, to introduce complexity into the discussion of a clinical case, and
on how this patient looks after an accident. A
to address moral distress. Table 2 illustrates each of these functions with fellow rebuts: “I think it would be wise to keep
an example. in mind that […] if this would have been a
patient with a closed brain injury [instead of an
3.3.1. Justifying or deflecting a moral course of action open brain injury], then we would not have
been just as perplexed and we might have
Many comparisons were justifications or deflections of some moral continued ICU treatment without any
course of action. Oftentimes, classic principles of clinical ethics such as hesitation” (Fellow, C6).
beneficence or respect for autonomy, may be argued to operate in the 2.8 An intensivist reacts to an ICU nurse who is
background of justifications, but they remain, more often than not, troubled by a patient’s suffering from work of
breathing: “It is a misconception that a high
implicit. This is illustrated by the statement of the intensivist from
work of breathing constitutes suffering. That is
Example 2.1 in Table 2, where the SCI analogy is invoked to argue to not the case: there are a lot of people with high
continue treatment for a patient who indicated not wanting to live with work of breath, but they do not suffer. We must
severe neurological damage. Example 2.2 provides a typical instance of keep that distinction in mind” (intensivist, C19).
the analogy which ICU professionals made between patients with sup­
posed end-stage diseases and patients with terminal cancer. In this case,
the analogy is invoked to argue in favor of offering palliative care.
While analogies aimed to positively justify a course of action often
provided avenues for further debate, deflective analogies had the

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N. Kok et al.
potential of ending the ethical dialogue all together. In Example 2.3, an
intensivist reacted to a number of ICU nurses who disagreed on
continuing treatment for a patient with TBI by pointing to other, recent
cases in which ICU professionals also anticipated that treatment of pa­
tients with TBI would be futile, while this eventually turned out not to be
the case. By this, the intensivist immunized the ICU nurses’ critique. The
facilitator reacted by mentioning that the intensivist evidently had
strong intuitions about this case, grounded in experience. Thereby, the
facilitator allowed the intensivist’s position to prevail without further
exploring the position of the ICU nurses.
3.3.2. Introducing complexity into the discussion about the case
Several case comparisons within the data introduced substantive
complexity within a case discussion. This most frequently occurs where
a clinical case was compared to a population of cases from the evidence-
based literature. In response to such comparisons, ICU professionals
sometimes remarked that this literature is not an adequate source to
compare a clinical case to, because the case fell, for instance, within the
exclusion criteria of a cited study. “You will never find certainty within
the literature,” one intensivist (C22) remarked during MCD. Example
2.4 further illustrates this. Another clear example would be a MCD about
a patient with COVID-19 and a rare autoimmune disease (C3). This
condition made the patient highly distinct from the average COVID-19
patient from the literature. During the deliberation, one of the inten­
sivists remarked that “it is rather complicated to add the mortality [of all
the patient’s different conditions] together. [The patient] cannot have a
mortality of a hundred and fifty percent. How do you add everything up?
One and one is three, in this case” (Intensivist, C3).
As such, the comparison of the patient-at-hand with patients from
the literature led ICU professionals towards using casuistic arguments
rather than applying an evidence-based deductive approach and into a
debate about whether the patient-at-hand is actually analogous with
average patients from the literature. In several MCDs within the dataset,
ICU professionals discussed patients which did not fit the literature
because they were too young, weighed too much or weighted too little,
had some rare disease or comorbidity, or suffered from a psychiatric
disease. Especially in pediatric medicine, a child’s prognosis twenty
years post-ICU “is based on historical cohorts” (PP5, interview), which
complicated comparisons with the literature. Casuistic comparison then
helped to deepen one’s moral understanding of a case, since evidence-
based literature did not always offer clearcut guidelines for medical
treatment of individual patients.
3.3.3. Addressing moral distress
There is a pattern across the cases in the data by which ICU pro­
fessionals made a claim about the suffering of patients based on their
direct sensory experience. ICU professionals then shifted into thera­
peutic nihilism and invoked the notion that continuing treatment would
be futile. Seeing suffering which is believed to be meaningless while at
the same time continuing treatment, caused moral distress in these
professionals. ICU professionals which were still optimistic and/or
hopeful about treatment addressed such therapeutic nihilism through
casuistic arguments. Within Table 2, Examples 2.6, 2.7, and 2.8 pro­
vide instances in which healthcare professionals addressed each other’s
distress by showing why it was not justified based on comparative pa­
tient cases or situations. Hence, analogies sometimes appeared to aim at
taking away the morally distressing experiences brought forward by
professionals who shifted into therapeutic nihilism. Example 2.6 does
so by a comparison of an addicted patient to other addicted patients
rather than comparing this patient to other ICU patients. As such, the
non-ICU physician proposed a different perspective of looking at the
patient-at-hand. In Example 2.7, the fellow attempted to take away the
distress of witnessing an open brain injury by stating that the same in­
ternal damage could have been sustained in a closed brain injury, while
that counterfactual case would not have caused the same sensory
experience of a suffering patient. In Example 2.8, lastly, an intensivist
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Social Science & Medicine 345 (2024) 116662
attempted to undercut the belief that a patient with a high work of
breathing is suffering, based on a comparison with other patients.
One intensivist characterized the difference between therapeutic
nihilists and – on the other hand – therapeutic optimists as one of “dif­
ferences in tempo” (PP1, interview), adding that ICU nurses, physicians
and families all have different levels of tolerance about how long a pa­
tient should be treated. Both the SCI analogy and the analogy to patients
with cancer addressed, in a way, tempo: the SCI analogy called upon
others to give more time to a patient to adjust and giving the patient a
chance, whereas the analogy to patients with cancer suggested that it is
time to move on to end-stage palliative care.
3.4. Question 3: what are the implications of using casuistry during the
moral reasoning processes on the ICU?
Three implications of using casuistry arise from the data: the impact
of seniority on the outcome of MCD, the risk that casuistry is not overtly
normative, and lastly, the risk of a quantitative fallacy when casuistry is
used within the framework of EBM.
3.4.1. Impact of participants’ seniority on the outcome of MCD
We observed during MCD that it sometimes matters for the outcome
of the MCD who was present and who did the reasoning. For instance, we
observed a junior intensivist who favored discontinuation of treatment
for a patient, but only on the condition that the patient would return
home. In response, a senior intensivist introduced the case of a previ­
ously similar “successful patient” (intensivist, C9) where treatment was
continued. The senior physician’s analogy was not disputed by any of
the other participants. Later, during the interview, the junior intensivist
said:
“I happen to know that [“successful” patient], and actually, it was
not such a good example. Because that [patient] was much younger.
[…] And [name senior colleague] used that example as an argument.
But it does not fit well with the [patient we discussed in MCD].
Because this patient is [much older]” (AP5, interview).
During the interview, the junior intensivist noted that it was, how­
ever, “a bit dangerous to go against the opinion of the senior physician.
Because, if the senior physician has an opinion on an approach within a
case, then it is almost impossible to argue for another approach” (AP5,
physician).
What this example suggests is that ICU professionals within MCD,
especially those with more expertise or higher up in the hierarchy, may
invoke reference to past cases that go unquestioned.
Residents indeed recognize that there is a large gap in terms of
accumulated case-knowledge: “In my year on the unit, I have seen about
ten [of these patients]. The intensivists have seen much more of them.
They hold a much bigger database of patients in their minds from which
they can make expert-based judgements” (R4, interview). Senior ICU
professionals indeed note that past experiences with variety across cases
leads them to be critical of their first impressions and judgements about
patients. But having a bigger database of patients also meant that case-
based arguments were sometimes used selectively to frame a moral
problem. One intensivist mentioned: “if I want to discuss either
continuing or withdrawing treatment with a colleague, then I can be
very selective in the colleagues with whom I discuss this and be selective
in how I present my case” (AP6, interview).
These observations, however, contrast with the tenets of principle-
based ethics as well as those of EBM. Ideally, with EBM, “[medical]
students would not need to rely on the expertise or proficiency of their
mentors; they would, instead, learn to assess the evidence on their own
(Hanemayer, 2016). And if moral reasoning was strictly deductivist,
“similar moral judgements are made by everybody, because equivalent
moral generalizations are applied alike by everybody to cases which are
perceived alike by everybody” (Urban Walker, 2007). Favoring deduc­
tivist arguments, both principlism and EBM ought to presume that it
N. Kok et al.
should not matter who makes an ethical or clinical argument: after all,
the acceptability or outcome of the argument should hold true based on
general principles, rules, guidelines or deductions from universal prin­
ciples or populations of patients. However, as the example we provide
above shows, it sometimes matters for the outcome of the MCD who was
present and who did the reasoning. In these cases, EBM offers young
physicians a critical attitude to test the objectivity of physicians that
apply case-based reasoning. The interviews additionally show that ICU
professionals seem to mostly suspect casuistic reasoning whenever it is
applied to problems that are more clearly clinical, but it is less suspect
when it is used in more purely ethical decision making (for insofar as the
clinical and ethical realm can be clearly demarcated).
3.4.2. Casuistry may forego utilizing overt moral language
The language of case-based arguments was most often not overtly
normative, and were not readily recognized as moral language by ICU
professionals. Rather, the data shows that casuistic reasoning deals with
the medical, ethical and contextual elements of decisions in an inte­
grated manner. Often, ethical arguments are implied in statements that
seemed, at face value, to be clinical or factual. The data contains almost
no explicit reference by ICU professionals to ethical principles such as
beneficence, nonmaleficence or respect for autonomy. It is, in fact,
mostly the facilitators who introduced ethical principles.
Case analogies could be seen to have two layers: an empirical layer at
which two cases were compared empirically, and a normative layer,
where a normative prescription in one case was extended to another
case. During many deliberations, the focus was on the empirical com­
parison between cases, and as such, casuistic reasoning was not always
explicitly moral reasoning. This means that while the invoked similar­
ities and distinctions between cases are clearly normative, this norma­
tivity is not always recognized-in-action. This risks fairly superficial
comparisons of cases where there is no subsequent inquiry into the
maxims behind the case and whether they hold true across cases.
An example is the instance of a patient with severe neurological
damage (C15), analogously understood to be a “kind of locked-in pa­
tient” (intensivist, C15). Prior to being admitted to the ICU, this patient
indicated not wanting to become a ‘vegetable’. During the MCD, the
reference to locked-in patients was dropped and replaced by the SCI
patient paradigm. SCI patients also express a preference for not
becoming a ‘vegetable’, but their treatment is nevertheless often
continued because their preferences are known to change. Here, the
background principle may have been that in some cases it may be
morally acceptable to override the patient’s autonomous choice. How­
ever, in the MCD of C15, the cases were only compared at the empirical
layer (i.e. that the patient had indicated not wanting to become a
‘vegetable’), but there was no consequent discussion of this underlying
ethical maxim, nor why the ethical maxims applicable to SCI patients
should be applied to this case, instead of ethical maxims applicable to
locked-in patients.
Additionally, the normative force of past, ‘closed’ cases that were
invoked as analogical cases was often taken for granted. This seems to
imply that there is broad consensus among ICU professionals about the
fact that what was done in past cases, was ultimately morally right. This
constitutes a risk, however, because seldom if ever do ICU professionals
reflect during MCD to ask whether past cases were indeed settled in a
morally appropriate way. Moreover, facilitators rarely check with other
participants whether they happen to know of the case which is invoked,
whether they recognize the ethical maxims implied in the case, and
whether there is consensus about the paradigm-status of that case.
3.4.3. Risk of quantitative fallacy
Many ICU professionals, during interviews, emphasized the priority
which population-based arguments should take over analogical argu­
ments. ICU professionals indicated that they fear wrongfully general­
izing from single case-to-case comparisons. One fellow said, “even if one
case seems similar to another one, you should try not to be led on by
7
Social Science & Medicine 345 (2024) 116662
appearances, but attempt to bring the larger populations back in” (F2,
interview). Another fellow added: “I try not to [make case-to-case
comparisons] […] for me, it is much more meaningful if a pulmonolo­
gist says: ‘I know ten cases and all have turned out as pulmonary crip­
ples, and it’s turned out dreadful for all of them’. That’s better than
knowing of a single patient” (F1, interview). A resident stated that “in
medicine we try to make our judgment not expert-based but evidence-
based, so you want large populations to compare with. […] The more
[of these patients] you have seen, the more your knowledge conforms to
how these patients truly fare” (R4, interview).
The data shows that during MCD, actual reasoning often deviated
from the forms of deductive reasoning ICU professionals preferred
during interviews. Several examples above show that during MCD,
population-based arguments ultimately became casuistic arguments,
especially when a patient-at-hand was seen as highly unique from the
average patients in the literature. The average case from population-
based studies was often really seen as a type of paradigmatic case.
This meant that if the average patient was compared to the patient-at-
hand, what appeared to be population-based reasoning was actually
analogical reasoning.
When this happens, there may be a “quantitative fallacy”, where it is
mistakenly assumed that comparing a patient-at-hand to an average case
deduced from the literature somehow differs from comparing the
patient-at-hand to another unique patient. In both instances, the source
patient functions as a paradigmatic case. This may result in a false sense
of certainty about the argument made, as well the mistaken assumption
that the moral action required in a paradigmatic case ought to be similar
to the moral action that is most frequently required across cases.
Within genuine casuistry, the correct moral action would however
not be arrived at by looking at how most physicians act in the face of a
moral problem. Casuistry derives moral imperatives from a qualitative
comparison of a clinical case to a specific other case which is likely to be
almost similar in ethical terms. Paradigmatic cases are cases in which
ethical maxims unambiguously hold, and these are not necessarily the
same as average cases (though they might be).
4. Discussion
This study asked how ICU professionals engage in casuistic reasoning
during MCD, what the function and purpose of casuistry is, and how
casuistry affects the moral reasoning process. Casuistry was ubiquitous
in MCDs where a decision had to be reached for a single ICU patient.
Analogies to other cases played a major role in ethical decision making
(Jordan, 1989). This study shows, furthermore, how references to the
medical literature and EBM oftentimes actually results in a casuistic
comparison of the patient-at-hand with an abstract, average patient. As
such, the results of the study lend support to the idea that clinicians use
empirical facts and knowledge derived from populations from the
literature in a casuistic fashion (Tonelli, 2010). It is essential that
apparent evidence-based reasoning does not provide ICU professionals
with a false sense of certainty about what would be a morally justified
action (Engebretsen et al., 2016), or worse: that the sometimes overt
moral language provides ICU professionals with a false sense that clin­
ical decisions are not also ethical decisions (Kelly et al., 2015).
This study demonstrates that, beyond direct reference to the medical
literature, naturalistic moral reasoning is prevalently analogical and
takes a narrative form (Urban Walker, 2007). Instead of introducing
principles to adjudicate cases, ICU professionals mostly reasoned
through paradigmatic cases which convey – implicit – some ethical
maxim. Some analogies (e.g. the SCI analogy) were repeatedly invoked
across deliberations. Thus, the practice we observed contained a set of
shared narratives that “put in a nutshell the view of conduct shared by its
reflective, responsible participants” (Jonsen and Toulmin, 1989, 342).
Several paradigm cases were ingrained within the ICU’s culture and
well-known across ICU professionals (Jordan, 1989; Kok et al., 2022).
This study especially highlights the SCI analogy and the analogy to
N. Kok et al.
patients with cancer. Albeit oftentimes no discussion took place about
the question whether some past case was settled in the right way, the
fact that ICU professionals come up with well-reasoned justifications to
deviate from solutions to past, settled cases, implies that the normative
content and force of such settled cases was also broadly shared and
accepted. In this, the study’s findings differ from Braunack-Mayer’s
study of general practitioner’s, who were only able to cite paradigm
cases from their own, private experience (Braunack-Mayer, 2001).
It has been argued that casuistry is ill-suited for MCD because
deliberating about “a sequence of similar cases and a comparison of their
similarities and dissimilarities would exceed the time frame available”
(Bleyer, 2020, 220). Additionally, comparing cases is not part of most
conversation methods for MCD (cf. Steinkamp and Gordijn, 2003). This
study shows, however, that casuistic arguments pervade natural ethical
decision making on the ICU, and that participants in MCD would do well
to recognize casuistic reasoning.
Casuistic arguments served to function as justifications, as a way to
introduce complexity within cases especially in juxtaposition to
population-based arguments, and lastly, as a way to address moral
distress among colleagues. ICU professionals recounted that they
sometimes strategically invoke case-comparisons to make other partic­
ipants adopt their perspective on a case. Facilitators of MCD have an
essential role in (supporting ICU professionals in) scrutinizing casuistic
arguments. They need to recognize when a case-to-case-comparison
becomes so influential to decision-making that it requires a more sys­
tematic exploration during MCD. Like any argument, analogies only
justify their conclusions when the premises of the analogies are them­
selves justified (Spielthenner, 2016). Getting those premises on the table
provides an impetus to scrutinize analogies. If a healthcare professional
introduces an analogy that becomes pervasive in the deliberation about
an ICU patient, facilitators would do well to ask other participants
whether they know of the past case and ask what the ethical maxims are
and whether all participants agree on a case’s paradigmatic status. It
would be beneficial for any groupwise moral reasoning process that any
invoked case is known by more than one participant. This will help
participants determine whether an analogy constitutes a genuinely good
argument.
While EBM guides most medical education curricula (Hanemayer,
2016), casuistic reasoning appears to be a significant part of ICU deci­
sion making. We therefore suggest that medical ethics and clinical
reasoning curricula should also strive to train medical students in
recognizing and engaging in casuistic reasoning and address the ques­
tion why a paradigm case illustrates a maxim (Ubachs-Moust et al.,
2008). There are, however, notable differences between casuistry as a
comprehensive methodology (e.g. Arras, 1991; Jonsen and Toulmin,
1989), and the applied casuistry in daily, ethical decision making in the
ICU. A full-fledged casuistry explores a series of cases and compares
paradigmatic cases with a plethora of less paradigmatic cases (Bleyer,
2020; Kok et al., 2022). In ICU practice, such a systematic exercise can
be done by organizing yearly retrospective reflections on a series of
cases encountered, so as to map out the ICU’s culture of decision making
and uncover a sort of “morisprudence” (Kok et al., 2022).
4.1. Strengths and limitations
A strength of this study was the possibility to analyze naturally
occurring language within MCD. The additional interviews allowed data
triangulation, since ICU professionals reflected back on the MCD in
which they participated. By integrating discourse analysis and a the­
matic analysis of the interviews, the ICU professionals who participated
in MCDs were more adequately represented within the data and the
analysis, reducing interpretative biases (Flick, 2018).
The findings of this study are based on an analysis of casuistic
reasoning in response to moral issues in single patients. This is an
important caveat, considering the large variety of moral problems on the
ICU. Examples of moral issues addressed during MCDs which were not
8
Social Science & Medicine 345 (2024) 116662
included were generic nursing dilemmas, pediatric end-of-life care, and
restriction of family visits during the COVID-19 pandemic. Moreover,
while this study shows that the clinical and ethical realms are closely
intertwined, casuistry can also be studied in relation to more purely non-
moral aspects of clinical decision making.
In 11 of the 25 MCDs in this study, no semi-structured interviews
were conducted. This was because interviewing started after an initial
period in which the researchers conducted only observations. Because
data saturation was, however, achieved among the 47 interviews that
took place across the 14 other cases, there is no immediate concern that
the absence of interviews in 11 cases biased the results.
A limitation of this study is that all participating ICUs were located
within the Netherlands and specifically employed MCD as a way of
addressing moral problems in ICU practice. Casuistry as a style of
reasoning may reflect an aspect of local ward culture, and may be
stimulated or hampered by elements of specific MCD methods (Stein­
kamp and Gordijn, 2003).
5. Conclusion
Casuistic reasoning is ubiquitous during ethical decision making on
the ICU. Facilitators of MCD should familiarize themselves with
analogical reasoning. Within medical education, we should strive to
train clinicians so that they can recognize and evaluate casuistic
arguments.
Funding
The research was supported by ZonMw, Project number 516012513.
CRediT authorship contribution statement
Niek Kok: Conceptualization, Data curation, Formal analysis,
Investigation, Methodology, Visualization, Writing – original draft,
Writing – review & editing. Cornelia Hoedemaekers: Conceptualiza­
tion, Methodology, Project administration, Supervision, Validation,
Writing – review & editing. Malaika Fuchs: Conceptualization, Re­
sources, Validation, Writing – review & editing. Hans van der Hoeven:
Conceptualization, Resources, Supervision, Writing – review & editing.
Marieke Zegers: Conceptualization, Formal analysis, Funding acquisi­
tion, Methodology, Project administration, Supervision, Validation,
Writing – review & editing. Jelle van Gurp: Conceptualization, Formal
analysis, Funding acquisition, Methodology, Project administration,
Supervision, Validation, Writing – review & editing.
Declaration of competing interest
None declared.
Data availability
Data will be made available on request.
Acknowledgements
The authors thank all ICU professionals and moral case deliberation
facilitators of the Radboud University Medical Center and Canisius
Wilhelmina Hospital who participated in and/or supported the study.
The authors thank Jos Kole (Radboud University Medical Center, IQ
health) for thoughtful exchanges on meta-ethical theory and casuistry.
Lastly, the authors are grateful to Irma Maassen (Radboud University
Medical Center, IQ health, Nijmegen) for support in data management
and analysis.
N. Kok et al.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.socscimed.2024.116662.
References
Arras, J.D., 1991. Getting down to cases: the revival of casuistry in bioethics. J. Med.
Philos. 16, 29–51.
Bleyer, B., 2020. Casuistry: on a method of ethical judgement in patient care. HEC Forum
32, 211–226.
Braun, V., Clarke, V., 2006. Using thematic analysis in psychology. Qual. Res. Psychol. 3,
77–101.
Braunack-Mayer, A., 2001. Casuistry as bioethical method: an empirical perspective. Soc.
Sci. Med. 53, 71–81.
Bingeman, E., 2016. Evaluating normative epistemic frameworks in medicine: EBM and
casuistic medicine. J. Eval. Clin. Pract. 22, 490–495.
Crowe, S., Cresswell, K., Robertson, A., Huby, G., Avery, A., Sheikh, A., 2011. The case
study approach. BMC Med. Res. Methodol. 11, 100.
Connors, G.R., Siner, J.M., 2015. Clinical reasoning and risk in the intensive care unit.
Clin. Chest Med. 36, 449–459.
Davies, R., Ives, J., Dunn, M., 2015. A systematic review of empirical bioethics
methodologies. BMC Med. Ethics. https://doi.org/10.1186/s12910-015-0010-3.
Erving, J.N., Kahn, J.M., Cohen, T.R., Weingart, L.R., 2018. Teamwork in the intensive
care unit. Am. Psychol. 73 (4), 468–477.
Engebretsen, E., Heggen, K., Wieringa, S., Greenhalgh, T., 2016. Uncertainty and
objectivity in clinical decision making: a clinical case in emergency medicine. Med.
Health Care Philos. 19, 595–603.
Fairclough, N., 2005. Analysing Discourse: Textual Analysis for Social Research.
Routledge, London.
Flick, U., 2018. Doing Triangulation and Mixed Methods. SAGE, Los Angeles.
Greckhamer, T., Cilesiz, S., 2014. Rigor, transparancy, evidence, and representation in
discourse analysis: challenges and recommendations. Int. J. Qual. Methods 13 (1),
422–443.
Haan, M.M., van Gurp, J.L.P., Naber, S.M., Groenewoud, A.S., 2018. Impact of moral
case deliberation in healthcare settings: a literature review. BMC Med. Ethics 19
(85).
Heidenreich, K., Bremer, A., Materstvedt, L.J., Tidefelt, U., Svantesson, M., 2018.
Relational autonomy in the care of the vulnerable: health care professionals’
reasoning in Moral Case Deliberation (MCD). Med. Health Care Philos. 21 (4),
467–477.
Hodges, B.D., 2008. Discourse analysis. BMJ 337, a879.
Hanemayer, A., 2016. Evidence-based medicine: a genealogy of the dominant science of
medical education. J. Med. Humanit. 37 (4), 449–473.
Social Science & Medicine 345 (2024) 116662
Hoffmaster, B., 1992. Can ethnography save the life of medical ethics? Soc. Sci. Med. 35
(12), 1421–1431.
Jonsen, A.R., Toulmin, S.E., 1989. The Abuse of Casuistry: a History of Moral Reasoning.
University of California Press, Berkeley.
Jordan, B., 1989. Cosmopolitical obstetrics: some insights from the training of traditional
midwives. Soc. Sci. Med. 28 (9), 925–944.
Kelly, M.P., Heath, I., Howick, J., Greenhalgh, T., 2015. The importance of values in
evidence-based medicine. BMC Med. Ethics 16, 1–8.
Khushf, G., 2013. A framework for understanding medical epistemologies. J. Med. Philos.
38 (5), 461–486.
Kok, N., Zegers, M., van der Hoeven, J.G., Hoedemaekers, C.W.E., van Gurp, J.L.P., 2022.
Morisprudence: a theoretical framework for studying the relationship linking moral
case deliberation, organisational learning and quality improvement. J. Med. Ethics
48, 868–876.
Little, M., Jordens, C.F.C., Sayers, E.J., 2003. Discourse communities and the discourse of
experience. Health 7 (1), 73–86.
Oerlemans, A.J.M., van Sluisveld, N., van Leeuwen, E.S.J., Wollersheim, H., Dekkers, W.
J.M., Zegers, M., 2015. Ethical problems in intensive care unit admission and
discharge decisions: a qualitative study among physicians and nurses in The
Netherlands. BMC Med. Ethics 16 (9).
Spielthenner, G., 2016. The casuistic method of practical ethics. Theor. Med. Bioeth. 37,
417–431.
Steinkamp, N., Gordijn, B., 2003. Ethical case deliberation on the ward. A comparison of
four methods. Med. Health Care Philos. 6, 235–246.
Stonington, S.D., 2020. “Making moves” in a cardiac ICU: an epistemology of rhythm,
data richness, and process certainty. Med. Anthropol. Q. 34 (3), 344–360.
Thompson, D., 2007. Principles of ethics: in managing a critical care unit. Crit. Care Med.
35 (2), s2–s10.
Tonelli, M.R., 2010. The challenge of evidence in clinical medicine. J. Eval. Clin. Pract.
16, 384–389.
Ubachs-Moust, J., Houtepen, R., Vos, R., ter Meulen, R., 2008. Value judgements in the
decision-making process for the elderly patient. J. Med. Ethics 34, 863–868.
Urban Walker, M., 2007. Moral Understandings. A Feminist Study in Ethics. Oxford
University Press, Oxford.
Van Baalen, S., Boon, M., 2015. An epistemological shift: from evidence-based medicine
to epistemological responsibility. J. Eval. Clin. Pract. 21, 433–439.
Wieringa, S., Engebretsen, E., Heggen, K., Greenhalgh, T., 2021. Clinical guidelines and
the pursuit of reducing epistemic uncertainty. An ethnographic study of guideline
development panels in three countries. Soc. Sci. Med. 272, 1–9.
Wubben, N., van den Boogaard, M., van der Hoeven, J.G., Zegers, M., 2021. Shared
decision-making in the ICU from the perspective of physicians, nurses and patients: a
qualitative interview study. BMJ Open 11, e050134.
Yin, R.K., 2014. Case Study Research, fifth ed. Sage, Los Angeles.
Zussman, R., 1992. Intensive Care: Medical Ethics and the Medical Profession. The
University of Chicago Press, Chicago.