The Moral Reasoning of Genetic Dilemmas Amongst Jewish Israeli Undergraduate Students with Different Religious Affiliations and Scientific Backgrounds

Cultural Influences on Scientific and Genetic Conceptions

Like decision making, comprehension of scientific and genetic information is also affected significantly by cultural influences (Lee et al. 2005; Pivetti and Melotti 2013; Shaw and Hurst 2008). Culture is defined as the totality of beliefs, values, behaviors and communication patterns among members of a cultural group (Parette 1999). Research on the relationship between culture and learning about science has shown that only when students’ culture is taken into consideration can there be significant learning and higher achievement (Lee et al. 2005). while integration of religious beliefs into the understanding of science reduces the tension between these domains (Starr 2010). Science education researchers cast culture as a system of implicit and explicit beliefs and values located within entities (e.g., individuals, groups), or a set of dynamic practices constructed and reconstructed through participants’ engagement in community activities (Parsons and Carlone 2013).

As a part of our cultural background, our religious beliefs affect our approach to science in general and to genetics in particular. This has been shown in cases as wide ranging as Muslim society in Saudi Arabia (Aqueel 2007). Chinese society in Australia (Ota Wang 2001). Pakistani society in Great Britain (Shaw and Hurst 2008) and religious women in Italy (Pivetti and Melotti 2013). In Israel, where our study took place, differences in religious belief and custom are clearly reflected in differing genetic practices. In the ultra-religious Jewish society, women refrain from doing amniocentesis because of religious restrictions that forbid selective terminations, whereas in secular Israeli society prenatal diagnosis and selective termination are supported, independently of the rabbinical stance (Raz 2009). The rejection of pregnancy termination by many religious communities often prevents participation in genetic testing (Rosner et al. 2009). The National Religious sector in Israel shows a higher percentage of performing genetic tests than the Ultra-Orthodox community, but still lower than in the secular sector (Sher et al. 2003). Thus, in these societies, the “options” raised by the genetic counselor can at times contradict the religious or traditional values of the patient.

Many religious populations that have been investigated believe that only God knows why a given situation occurs. They therefore do not wish to intervene before or during pregnancy, believing the situation to be out of their control anyway (see for instance Ngim et al. 2013; Pivetti and Melotti 2013; Shaw and Hurst 2008). And yet, studies have also shown that there is not always an exact correlation between belief and behavior. Though religious people usually prefer to rely on God, there are cases when - despite the fact that religious rules do not permit termination - some religious people nevertheless choose to do so if their fetus is sick (Raz 2009).

Decision Making

Throughout our life, we are required to make decisions on a wide range of topics. We are usually not taught to make these decisions, and most are therefore intuitive, influenced chiefly by our own values (Saaty 2000). Researchers have realized that the participation of the public in scientific decisions is crucial, since the public no longer trusts scientists blindly, and areas such as genomics and modified food are giving rise to many ethical and social dilemmas in which the scientists are trying to involve the public (Wilsdon and Willis 2004). As the public gradually becomes more involved, their decision making must also become more informed. To ensure informed decision making on genetic issues, more effort must be invested in presenting the benefits, risks, and limitations of genetic testing, since genetic issues are scientifically complicated, and as a result even genetically educated societies can sometimes show a lack of understanding of the consequences of testing (Haga et al. 2013).

Moral Reasoning

Moral reasoning is a procedure in which one decides what one ought (morally) to do on the basis of one's values. Prior qualitative analysis has revealed that moral considerations can significantly influence the decision making processes (Sadler and Zeidler 2005). People tend to rely on moral factors when making decisions on socio-scientific issues (Bell and Lederman 2003). which means that socio-science issues are linked to moral reasoning. High levels of moral reasoning have been described in terms of cognitive flexibility, or the ability to understand, consider, and weigh multiple frameworks (Endicott et al. 2003). It has been found that participation in formal education, such as higher education, develops moral reasoning (King and Mayhew 2002).

Values are known as one of the components that influence the making of choices between alternative courses of action (Dietz et al. 2005; Kortenkamp and Moore 2001; Oreg and Katz-Gerro 2006; Stern et al. 1999; Stern 2000). For the purpose of our study, values are defined as: the principles people use to select and justify their actions and to evaluate people and events. The value priorities of individuals are affected by their social experiences, such as religion, gender, education, occupation, and cultural background. In turn, they also influence those individuals’ actions in domains such as religion and environment (Schwartz 1992).

When dealing with the moral reasoning of individuals on genetic health issues, and with the values reflected therein, we must be aware of the norms and values at risk in controversial issues such as prenatal diagnostics and pre-symptomatic genetic testing, which confront people with difficult choices (Van der Zande et al. 2012). Since test outcomes are ambiguous and other people (i.e. family members) are also involved, people often base their choices on moral grounds, and not necessarily on scientific knowledge (Van der Zande et al. 2012). High school students have been found to make significant use of moral reasoning when discussing genetic tests (Lindahl 2009). genetic engineering (Sadler and Zeidler 2005) and biotechnology (Dawson and Venville 2009). Students employed moral reasoning by using cognitive rationalistic reasoning at times, and by using emotive reasoning at others (Dawson and Venville 2009; Lindahl 2009; Sadler and Zeidler 2005).

Gender Influences

Since decision making is affected by behavioral characteristics, it is quite likely that gender will be a factor that influences decision making in the context of genetic counseling. Women can have different considerations, values and concerns than men, and are also perceived differently than men in different cultures (Awwad et al. 2008; Inglehart and Norris 2003; Loo and Thorpe 1998; Signorielli 2012). Gender has been found to influence ethical decision making (Beekun et al. 2010; Curtis et al. 2012; Jaffee and Hyde 2000; Rothbart et al. 1986). as well as risk preference (Taylor 2011). with women having been found to be less risk seeking than men (Powell and Ansic 1997). All these differences might influence men and women's elaborations on moral decisions concerning genetic issues.

Objective and Research Questions

Participants

Our study population was composed of undergraduate students from 4 out of the 5 Israeli universities as well as two colleges for teacher training. We focused specifically on undergraduate students because they are at the relevant age for genetic counseling concerning birth defects and genetic diseases.

Our goal in constructing the sample was to achieve a large enough sample of each of our six basic categories (i.e. religious students vs. non-religious ones, life-science studiers vs. non-life-science studiers, male vs. female students). We therefore appealed by email, at the beginning of the 2013 academic year, to lecturers in all Israeli universities and colleges who teach a variety of subjects that are studied at universities. Of these, 50 % were willing to participate and allowed us to distribute the questionnaire in their classes. With those, we arranged a mutually convenient time during the semester to come to their class and distribute our questionnaire. The students were told that the questionnaire was non-mandatory, that their answers were confidential and that its findings would be used for research purposes only. Completing it took approximately 30 min, and was done during the lesson, with one of the researchers present to answer questions. We continued to administer the questionnaire and collect data throughout the 2013 academic year until we achieved a sample that we judged to be sufficiently large and balanced.

The final sample consisted of 449 Israeli undergraduates. We approached 560 students on the whole, of whom 20 % declined to participate. Seventy three percent of the students in the final sample study in universities and the rest in colleges. Fifty seven percent of the students were female, the rest male; 51 % identified themselves as religious or semi-religious and the rest were secular. Fifty four percent studied life sciences (LS) and the rest studied subjects with no connection to genetics, such as economics, education or computer engineering.

The first part of the questionnaire asked the students about their personal details. We asked the students to circle the religious affiliation that suits them: secular, semi-religious, National religious or Ultra-orthodox (all well-known categories used in everyday discourse to define religious identity in Israel). In this way the sample “self-identified” the students’ religious affiliation. It should be noted that this research was found to be exempt from ethics review since the interview was voluntary, anonymous and did not include any disclosure of health information of any kind.

One important limitation to note in our sample is that it does not include students from Israel's non-Jewish population, which includes Christian and Moslem Arabs, Druze, and Bedouins. Of the students who answered our questionnaire, only 3 % identified themselves as non-Jewish, a percentage far too small to produce accurate results. We therefore omitted them from our sample, and we shall not relate in this study to the non-Jewish Israeli population.

Questionnaire Description

The questionnaire started with a short knowledge test consisting of 6 multiple choice questions (Appendix 1) that are part of the tool developed by Bowling et al. (2008). The questions were chosen from different concepts identified in the Bowling tool as central to genetic literacy. This part of the questionnaire is only intended to clarify the difference, if one exists, between the genetic knowledge of students studying and not studying life sciences.

The main part of the questionnaire included a genetic dilemma with 2 open ended questions (Table 5), and 4 scenarios with statements (Table 6). The participants were asked to state their agreement with each statement and explain their answer in their own words.

Data Analysis

The answers to the qualitative questionnaire, including the genetic dilemma and 9 open-ended elaborations to statements from 4 scenarios, were categorized according to the method suggested by Sadler and Zeidler (2004) for classifying the moral decision-making of students about genetic engineering dilemmas. Their study collected qualitative data through interviews, dividing the students’ responses into 2 major categories: moral consequences (MC) and non-consequentialist moral principles (MP). MC was indicated by “consequentialism, when students justified their positions in terms of expected outcomes” (Sadler and Zeidler 2004 pp. 14). while decisions in the moral principles category were based on “moral standards independent of the consequences” (Sadler and Zeidler 2004 pp. 16). We adopted this basic categorization, used some of the sub-categories which had been written by Sadler & Zeidler and added sub-categorizations that were relevant to the genetic counseling dilemmas raised in our questionnaire.

Questionnaire Validity and Reliability

The questionnaire was validated in several stages. In the first phase a representative sample of 20 full questionnaires was divided into categories by the first author of this article. The categories of these 20 questionnaires were semantically validated (Bauer and Gaskell 2000) by the co-author and by two other independent researchers (Creswell and Miller 2000). All four researchers, two experts in genetics and two experts in science education, each classified the answers into categories on their own. Elaborations that led to any disagreements were discussed until a 90 % agreement on the elaboration categories was reached (Vedder-Weiss and Fortus 2012). At the second stage, the rest of the questionnaires were categorized by the first author, and revised by the co-author according to the final categorization agreed upon. Elaborations that led to any disagreements were discussed until an 85 % agreement on the elaboration categories was reached (Vedder-Weiss and Fortus 2012).

Statistical Analysis

The major student elaborations (MC and MP) were statistically analyzed using the Nominal (=Binary) Logistic Regression model, utilizing significant variables (p ≤ .05). Our two levels were either an MC or an MP elaboration. The purpose was to determine the impact of multiple independent variables presented simultaneously to verify which of the independent variables (religious affiliation, gender or field of study) differentiates between moral consequences and moral principles elaborations. The type of elaboration - moral consequences (MC) versus moral principles (MP) was the dependent variable (Tables 1, 2, and 3). In order to account for multiple inferential tests, Holm–Bonferroni method was applied on the results. Nagelkerke's R^2 was calculated to be 0.05 for our models.

Power analysis was calculated by Sensitivity in G*Power 3.1 software, for statements 3, 7 and 8. We found that with a statistical power 0.80, α = 0.05, sample of 449 students, when the groups are equal in size, the smallest OR the test could detect is 1.73.

Religious Affiliation Among Jews as an Influencing Factor

We focused specifically on religious affiliation as a central variable, since studies have shown that there is a relationship between religion and ethical decision making processes in ethical situations (Nucci 2001; Wagner and Sanders 2001). Faith and religion have previously been shown to be influential on questions of the meaning and essence of life (Alvarado et al. 1995; Atkinson and Malony 1994; Williams et al. 1991). Likewise, studies done on religion and health have shown that certain religious beliefs can interfere with the timely seeking of medical care, and may delay diagnosis and treatment, since religious believers rely at times on faith rather than traditional medical care (Koenig et al. 2012). These discoveries go some way towards explaining our findings that some differences between students’ elaborations were related to their religious affiliation.

In Israel, differences in religious belief and custom are clearly reflected in differing genetic practices, with some sectors rejecting participation in genetic testing due to their religious beliefs (Raz 2004; Rosner et al. 2009; Sher et al. 2003; Zlotogora 2002). Moreover, Jewish religious students, especially those who do not study life sciences, have been found to place less trust in genetic tests than secular students do (Siani and Assaraf 2015). An understanding of the differences between various religions and the beliefs associated with them will help us understand the manner in which individuals relate to the tension between faith and science (Dickerson et al. 2008). Because genetic counseling can sometimes contradict religious positions, it is necessary (if such counseling is to be successful) to understand the impact of religion on the process of decision making in the context of genetic counseling (Weil 2001). In Southeast Asia for example, researchers have indicated the importance of reflecting the culture and context-specific nature of genetic counseling and consultation encounters, and cited the counselees’ religion as a major influence (Zayts et al. 2013). In our research as well as in others (Pivetti et al. 2012). the importance of religion does not emerge openly in the participants’ discourse, though it influences the positions expressed on termination, and consequently the attitude towards genetic testing.

Gender as an Influencing Factor

In addition to religious affiliation among Jews, we found that gender had some measure of influence on the moral considerations of students. In most cases, the influence of gender on ethical decision making was found to be inconsistent - significant in one context but not in another (Byrnes et al. 1999; Curtis et al. 2012). This was reflected in our study as well. When dealing with a late onset genetic disease, men showed a more principle based approach than women, perhaps because women's role as primary caregivers and their involvement with childbearing leads them to take a more practical, consequence-based approach (Shiloh 1994; Tibben 1993). On the other hand, in the context of future ethical considerations, women tended to be more concerned with moral principles, which may reflect their concern with genetic procedures that are only performed on women. We can therefore conclude that gender has a mixed pattern of influence on moral considerations and is a less influential factor than religious affiliation, in which the pattern was a bit more consistent.

Field of Study as an Influencing Factor

The moral considerations of life sciences learners in comparison to non-learners did not differ distinctly in most parts of the questionnaire. Since formal scientific background has been shown to have an influence on students’ negotiation of socioscientific issues (Hogan 2002; Tytler 2012; Zohar and Nemet 2002). and since types of values broaden as a result of studying a certain discipline (Solli et al. 2014). we thought that our students’ elaborations might be impacted by their genetic knowledge. However, we did not find the pattern we expected, and we did not find that prior scientific knowledge had an influence on the students’ elaborations when dealing with most of the genetic issues in the questionnaire.

That said, we did find a difference in the context of late onset diseases, where the Jewish religious students who study life sciences tended towards a more consequentialist approach than religious students who do not, perhaps because they are more aware of these kinds of diseases and their genetic and psychological meaning (Evers-Kiebooms et al. 2000). Yet another explanation might be that these religious students’ science education has made them less concerned with their religious principles by broadening their scope to include additional considerations. Finally, it might mean that the religious non-LS students are more concentrated on their principles and less conscious of the consequences that the genetic situation might bring.

The Issue of Pregnancy Termination

Genetic counselors are trained to present information and facilitate their patients’ decision making without letting their own religious or moral beliefs influence them in any particular direction (Woltanski et al. 2009). This requirement relates to all aspects of the counseling, including the delicate issue of termination (Stephens et al. 2010).

Three of the statements in the questionnaire deal with examining the fetus for genetic disorders that involve the possibility of termination, which is a complex issue with many uncertainties, and as such produces differing interpretations and rulings in Judaism (Schiff 2002). Although there is a fundamental agreement on the distinct Jewish attitude against termination, circumstances do affect this general agreement, for instance if the pregnancy endangers the life of the mother (Stephens et al. 2010). Some lenient Jewish scholars permit termination for any “major defects” that might occur in the unborn child, and defects that make the mother and the family anxious about the future (Gordis 1978). The more stringent consensus position of most Orthodox scholars is to oppose termination even for fatal disorders. Though this consensus exists, some religious scholars, like Waldenberg and Yisraeli, do allow termination if a fatal disease is detected in the fetus (Schiff 2002). An interesting innovation is that in all of the statements that dealt with the option of terminating the pregnancy in this research, there is no significant difference between the religious and secular students’ elaborations, even though it is an issue that is known to be problematic in Judaism. A partial explanation for this finding might be that nowadays the Jewish religious population in Israel is highly integrated into secular society (Herman et al. 2014). The religious sector works in all places: in the high-tech industry, in the army, in the communication system and so on, and sees itself as a part of the general society, as well as observant of religious rules. The finding relating to termination could be a reflection of this relatively new “Westernization” that the religious sector is heading towards, and of the influence of the secular society with whom they work, study and live closely.

Practical Implications

Study Limitations

Since this questionnaire was distributed among undergraduate students, it is in effect adapted for – and reflective of - young people of medium and high socioeconomic status. Our research population therefore does not reflect all of the Israeli Jewish population, and the questionnaire should be modified if needed for a variety of populations, as has previously been done with a questionnaire testing informed choice (Dormandy et al. 2007). This modification would make the questionnaire available to diverse populations, enabling a comparison of the moral considerations of citizens from different cultures (Zeidler et al. 2013).

In addition, the fact that the participants answered the questionnaire while at the university campus is a limitation of the study. Their response might be affected by social desirability since they may think that as students they are expected to be more liberal, and to relate to universal codes rather than their own moral considerations when asked about moral issues. Perhaps the same population would have reflected its doubts more intensively in a different setting.

The volunteer sampling is another study limitation, since perhaps the students that are particularly interested in genetic topics were the ones who were willing to answer the questionnaire, while others who were less aware of these topics did not answer it at all. This limitation may have tilted the results.

In future research using this model, we suggest the use of the genetic quiz (attached in Appendix 1) as a predictor of the genetic knowledge of the student either in place of or in addition to the status of the student as a life-science major or not. This genetic quiz would give a more detailed picture of the impact of genetics knowledge and be a better predictor with less measurement error. A limitation of this study is that we did not use this approach and for that reason we might have made errors in predicting the genetic knowledge of our students.

Finally, though moral reasoning considerations have been shown to influence decision making (Bell and Lederman 2003; Sadler and Zeidler 2005). our study, which was based on a series of hypothetical scenarios, did not actually witness the transition from reasoning to decision making. More research is needed in order to further analyze the mechanisms and factors that influence moral reasoning, and to determine whether and how this reasoning ultimately translates into moral decision making.

Research Recommendations

Religious commitment is a very personal issue, which has not been investigated from a personal angle in this research. In order to gain better insight into the students’ attitudes and values, in-depth interviews can be held with students to add further clarity and context to what they mean by each of their elaborations. These interviews could include explicit questions regarding religious considerations, and issues that have not yet been fully analyzed can be focused on more carefully.

In addition to the religious aspect, the interviews would also cover the personal and familial health experiences and perceptions of the interviewee, factors that play a central role in how individuals remember, interpret, and respond to disease risk information (Gordon et al. 2012; Kaufman et al. 2012). A more complete understanding of the reasons for decisions about whether to have genetic testing or not, which we would hopefully achieve through the interviews, would help counsellors to better communicate with women and couples, and better assist them in making informed decisions about genetic testing (Pivetti et al. 2012).