Research and Scholarship

Case-Based Learning in Ethics

Putting the Hay Down Where the Goats Can Get It

In the tales about the fictional town of Lake Wobegon, the character Val Tollefson, Pastor Ingqvist’s “faithful critic,” says of the pastor, “He never puts the hay down where the goats can get it. It’s a lot of talk, and many a Sunday I’ve walked away with no idea what he said.” Clinical and research ethics are applications of the broader field of ethics, which has its foundations in philosophy and theology. Within ethics, there are those who do empirical work (data-based research to determine attitudes and practices related to ethical issues) and those who do conceptual work (using the tools of philosophy to determine how an ethical issue should be analyzed in an effort to come to a reasonable solution to the problem. Much of this conceptual work, however, provides less than clear guidance regarding practical application in the clinical or research environment.

Over the last three decades, emergency medicine physician and bioethics faculty Dr. Douglas Diekema has attempted to “put the hay down where the goats can get it,” doing conceptual work in bioethics in a way that becomes translational – understandable and easily applied in a clinical environment. As part of that work, he has been a leader nationally in creating educational materials for teaching bioethics. When Diekema started working at Seattle Children’s Hospital in 1990, there were no published resources for teaching ethics to pediatric clinicians.

This lack of resources led him to create a pediatric residency ethics curriculum in 1997 to train medical students and residents. Twenty years later, the American Board of Pediatrics requires that programs for pediatric residents include “structured curriculum in medical ethics that addresses the ethical principles of medical practice and the ethical aspects of a physician’s relationship to patients, other physicians and society.” To remedy the paucity of resources, the American Academy of Pediatrics (AAP) Section on Bioethics now publishes online modules in bioethics. Diekema authored one of the modules and serves as one of the three editors who oversee the project, which underwent a complete revision in 2017.

In 2011, Diekema and two collaborators published Clinical Ethics in Pediatrics: A Case-Based Textbook. The textbook provides a comprehensive introductory text on clinical ethics for healthcare professionals who take care of children and a teaching resource for those who teach ethics to medical students, residents and others. Each chapter begins with a case to ground the ethical issues and concepts in real-life examples from the clinical realm. Many clinical educators nationally and internationally use the text as a resource for their teaching.

As a member of the AAP's Committee on Bioethics, Diekema has authored and contributed to policy statements and guidelines on far-ranging topics to provide guidance to clinicians surrounding ethical issues they face when caring for children. Many of his publications attempt to distill complex ethical issues into a clinically useful approach. Additionally, he wrote a key paper about the limits of parental decision-making authority and how to approach clinical situations in which a parent is resisting or refusing a medical recommendation.

“So many difficult ethics cases seem like a muddled mess to the clinician. My goal is to organize that mess, provide a framework for understanding it, and ideally point the way toward a solution to a complex and often distressing situation. My teaching focuses on getting clinicians to think about these issues ahead of time and provide them with a toolbox that they can access in thinking through the ethical issues we face in medical practice or a research environment.”

Dr. Doug Diekema

Ultimate Goal

To bring clinical ethics as it relates to pediatrics to a wider audience and translate bioethics for the clinician.


  • Mark Mercurio, Yale University School of Medicine

Representative Publications

Visit American Academy of Pediatrics Section on Bioethics for more information.