Skip to main content
Download PDF

Perceptions of ethical decision-making climate among clinicians working in European and US ICUs: differences between religious and non-religious healthcare professionals

BMC Medical Ethics volume 26, Article number: 21 (2025) Cite this article

Abstract

Background

Making appropriate end-of-life decisions in the intensive care unit (ICU) requires shared interprofessional decision-making. Thus, a decision-making climate that values the contributions of all team members, addresses diverse opinions and seeks consensus among team members is necessary. Little is known about religion’s influence on ethical decision-making climates. Therefore, this study aimed to examine the association between religious belief and ethical decision-making climates.

Methods

The study was a cross-sectional analytical observation study as a part of the prospective observational DISPROPRICUS study. A total of 2,275 nurses and 717 physicians from 68 ICUs representing 12 countries in Europe and the US participated. All participants were asked which religion (if any) they belonged to and how important their religion (if any) was for their professional attitude towards end-of-life care. Perceptions of ethical decision-making climates were evaluated using a validated, 35-item self-assessment questionnaire that evaluates seven factors. Using cluster analysis, ICUs were categorised into four ethical decision-making climates: good, average (with nurses’ involvement at the end of life), average (without nurses’ involvement at the end of life) and poor.

Results

Of the 2,992 participants, 453 (15%) were religious (had religious convictions and found them important or very important for their attitude towards end-of-life care). The remaining 2,539 were non-religious (i.e. had religious convictions but assessed that they were not important for their attitude towards end-of-life care). When adjusting for country and ICU, the overall perception of the four ethical climates was associated with religious beliefs, with non-religious healthcare providers having more positive perceptions of the ethical climates compared to religious healthcare providers (p < 0.01). Within good climates, non-religious healthcare providers rated leadership by physicians (p < 0.01), interdisciplinary reflection (p = 0.049) and active decision-making by physicians (p = 0.02) as more positive compared to religious participants. In poor climates, religious healthcare providers had a more positive perception of the active involvement of nurses (p = 0.01). Within the other climates, no differences were found.

Conclusions

Overall perceptions of ethical decision-making climates were associated with religious beliefs, with non-religious healthcare providers generally having a more positive perception of the ethical climates than religious healthcare providers.

Peer Review reports

Background

Making the most appropriate end-of-life decisions in the ICU requires shared, interprofessional decision-making [1]. To foster this requirement, a decision-making climate that values the contributions of all team members, addresses diverse opinions and seeks consensus among team members is necessary [1]. Poor ethical decision-making climates (EDM-Cs) may lead to suboptimal decision-making processes and the provision of excessive care [2]. Likewise, a poor EDM-C may entail team conflicts, poor family support, moral distress, burnout and intent to leave [1, 3].

A good decision-making climate requires interdisciplinary communication and collaboration [1, 4], empowered by physicians [5], and an ethical working environment that facilitates the possibility of ethical debate, includes nurses in decision-making and tolerates different opinions and values [6]. Nurses have been found to consistently perceive ethical climates in ICUs as worse compared to physicians across different climates [7,8,9], and nurses are prone to leave their ICU jobs if they experience moral distress at work [9, 10].

There are differences among the world’s major religions when it comes to decision-making in the ICU, especially concerning the withdrawal of life-sustaining treatment [11]. This may lead to conflicts between religious believers and nonbelievers or conflicts between different religious groups when decisions must be made. Among religious physicians, 15–30% will not follow a competent patient’s wish to abstain from treatment [12], and an analysis of 112 standardised, simulated ICU family meetings found that the self-reported religiosity of intensivists was associated with increased odds of perceived conflicts during the simulated meeting with an actor portraying a religious family surrogate [13].

Little is known about the influence of religion on EDM-Cs. Therefore, the aim of the current study was to examine the association between religious beliefs and EDM-Cs. The hypothesis was that non-religious healthcare providers (HCPs) would rate their EDM-Cs higher than religious HCPs would rate their EDM-Cs.

Methods

This was a cross-sectional analytical observation sub-study of the DISPROPRICUS study, which examined the possible association between EDM-Cs and prognostic values (patient outcomes) when nurses and physicians in a 28-day period perceived the care provided to be excessive [2]. ICUs were selected via the Ethics Section of the European Society of Intensive Care Medicine, from the APPROPRICUS study group [14] and via contact with experts in communication and end-of-life (EOL) care. From April–May 2014, personal data– including profession, rank, sex, age, ICU experience, religious beliefs and importance of these beliefs together with perceptions of EDM-Cs were evaluated among clinicians from 68 adult ICUs in 12 European countries (Belgium, the Czech Republic, Denmark, France, Germany, Greece, Hungary, Italy, Portugal, the United Kingdom, Sweden and the Netherlands) and the United States (US).

The tool used was the validated, self-assessed Ethical Decision-Making Climate Questionnaire (EDMCQ; [6]), which is based on the ICU Safety Attitude Questionnaire [15], the Leader Behavior Description Questionnaire (LBDQ; [16, 17]), the Interprofessional Practice and Education Quality Scale (IPEQS; [16, 18]) and the questionnaire used in the APPROPRICUS study [14]. The theoretical framework behind the EDMCQ and the EDMCQ tool were developed through a modified Delphi method [6]. It encapsulated three key domains of ethical decision-making (EDM) within the healthcare context: interdisciplinary collaboration and communication; leadership by physicians; and the ethical environment. The EDMCQ was subsequently validated using both exploratory and confirmatory factor analyses [6]. Additionally, measurement invariance was assessed to ensure that the variables utilised in the analysis represented comparable constructs across diverse groups [6]. In addition to the EDMCQ, questions regarding HCP characteristic were included. These questions were based on a former questionnaire [14] and tested for face and content validity by participating HCPs from different countries. The study questionnaire was first presented as supplementary material in [2], but can also be found as supplementary material in this paper (Table S1). The questionnaire was developed in English and subsequently scientifically two-way translated into the languages of the participating countries. All HCPs at the participating ICUs were asked to fill in the questionnaire which was available electronically on the DISPROPRICUS study website to which each HCP received a personal log-in.

Religious beliefs

The two questions regarding religion were: (1) “What is your religion?” with response options: “Roman Catholic, Protestant, Greek-Orthodox, Muslim, Jewish, Buddhist, Non-religious, I do not wish to answer this question”, and (2) “How important is your religion for your professional attitude towards your professional end-of-life decisions?” with response options: “Not important, Not very important, Important, Very important”. For analysis, the data containing information on HCPs were split into data on religious HCPs (those rating the importance of their religion as important or very important in their attitude towards EOL care) and 2) non-religious HCPs (those identifying as non-religious as well as those identifying with a specific religion but rating the importance of their religion as not very important or not important in their attitude towards EOL care).

Ethical decision-making climates

Developed using explorative and confirmatory factor analyses [6], the final model of EDM-Cs included seven meaningful factors (F): F1. self-reflective and empowering leadership by physicians, F2. a practice and culture of open interdisciplinary reflection, F3. a culture of not avoiding EOL decisions, F4. a culture of mutual respect within the interdisciplinary team, F5. active involvement of nurses in EOL care and decision-making, F6. active decision-making by physicians and F7. a practice and culture of ethical awareness. The questions included in each factor [7] and the full questionnaire with response options and factor analyses [2] have previously been published.

To identify possible types of ethical climates within all participating ICUs, a dimension reduction was carried out by means of cluster analysis using the seven factors identified [2]. Each ICU provided responses from several clinicians, each with their own perception of that ICU’s ethical climate. The average score across HCPs for each factor in a given ICU was calculated and used as input for the cluster analysis at the ICU level. The cluster analyses yielded four grades of EDM-Cs: good, average (with involvement of nurses at the end of life), average (without involvement of nurses at the end of life) and poor. Good climates are characterised by active leadership among senior clinicians and mutual respect, which enables interdisciplinary reflection and decision-making overall. HCPs in average (+) climates still had a positive perception of their EDM-C but reported lower scores on average for each of the factors. In comparison to the average (+) climates, there was a negative perception of how actively nurses are involved in EOL care and decision-making in the average (-) climates. Finally, HCPs in poor climates perceived a need to improve in each of the seven factors [2].

Data analysis

Non-religious and religious HCPs were classified into the four EDM-C groups. To acknowledge correlations between measurements within ICUs and to adjust for the confounding effects of cultural differences not related to religion, mixed models adjusting for country as a fixed effect and ICU as a random effect were used to compare the overall perceptions of the four climates.

Furthermore, differences between religious and non-religious HCPs in perceptions of the EDM-Cs were assessed by comparing median factor scores for each of the seven EDM-C factors using adjusted-median mixed models with country as a fixed effect and ICU as a random effect. This comparison was first made with the entire sample of HCPs and subsequently within each of the four ethical climates separately. A p-value < 0.05 was considered significant.

Results

A total of 717 physicians and 2,275 nurses participated in the study, representing 68 ICUs from 12 European countries and the US. The overall response rate for the questionnaire was 63%; for physicians, it was 61%, and for nurses, 63%.

A total of 1,802 HCPs stated that they had a religious conviction or ticked ‘Do not want to answer’. Two-thirds were either Roman Catholics or Protestants. In supplementary table S2, percentages for each country are presented. Of those who had religious convictions, the majority found that these beliefs were not or were not very important for their attitude towards EOL care. Within religions, Greek Orthodox Christians and Muslims were likeliest to find that their religion was important or very important for their attitude towards EOL care (Table 1).

Table 1 Participants’ religious beliefs
Full size table

Of the 2,992 participating HCPs, 453 were considered religious (had religious convictions and found them important or very important for their attitude towards EOL care). The remaining 2,539 were considered non-religious (including those who had religious convictions but assessed that they was not important for their attitude towards EOL decisions) (Table 2).

Association between religious beliefs and end-of-life ethical decision-making climates

When adjusting for country and ICU, the overall perceptions of the EDM-Cs were associated with religious beliefs, with non-religious HCPs having a more positive perception of their ethical climates compared to non-religious HCPs (p < 0.01) (Table 2).

Table 2 Healthcare provider characteristics
Full size table

Within climates, non-religious HCPs rated leadership by physicians (adjusted difference in medians: 0.24, p < 0.01), interdisciplinary reflection (adjusted difference in medians: 0.11, p = 0.049) and active decision-making by physicians (adjusted difference in medians: 0.16, p = 0.02) as more positive compared to religious HCPs. In both average climates (with and without the involvement of nurses in EOL decisions), no significant differences were found in the perceptions of any of the seven EDM-C factors. In poor climates, religious HCPs had a more positive perception of the active involvement of nurses (adjusted difference in medians: 0.20, p = 0.01) (Table 3).

Table 3 Perceptions per climate
Full size table

When looking at the seven factors constituting EDM, no significant differences between religious and non-religious HCPs were found after adjusting for country and ICU (see the Supplementary Material, Table S3).

Discussion

After adjusting for country and ICU, the overall ethical climate ratings were associated with religious beliefs, with non-religious HCPs having a more positive perception of their ethical climates compared to religious HCPs. Within good climates, non-religious HCPs rated leadership by physicians, interdisciplinary reflection and active decision-making by physicians as more positive compared to religious HCPs. In poor climates, religious HCPs had a more positive perception of the active involvement of nurses in EOL care and decision-making. However, no significant differences were found between religious and non-religious HCPs when looking at the seven factors that constitute EDM-Cs.

In a time of rapid globalisation and growing cultural diversity, it is inevitable that clashes between belief systems will occur. In London, one-third of the population was born outside the UK, and over 300 languages are spoken in the capital [19]. This may lead to large variations in perceptions of both how work in the ICU should be conducted and what roles ICU nurses should play [20]. Many physicians from non-Western regions may be less experienced in using and working within the concepts of medical utility and futility. This may lead to prolonged ICU stays [21] and less-qualified communication [22] and, through this, have a negative influence on EDM-Cs. Bülow et al. found significant differences in EOL decisions between actively religious doctors, nurses, patients and families and those who identified themselves as merely affiliated with a religion. Religious respondents requested more treatment, were more in favour of prolonging life and were less likely to want euthanasia than those only affiliated with a religion [12]. These attitudes towards one’s own treatment are quite likely to be reflected in the decisions HCPs make on behalf of the patients. Another study discusses the possibility that religious intensivists whose religious traditions dictate a specific approach to EOL care face the possibility that a patient or surrogate (or colleague) will make a choice that conflicts with their physician’s personal values [13]. Secular intensivists may be more comfortable supporting a broader range of approaches to EOL care, placing them at a lower risk of experiencing this conflict and moral distress [13]. The current study indicates an association between religion and evaluation of EDM-Cs, suggesting that, to promote a good EDM-C, it is important that there be an openness towards religion-based opinions, and ICU leadership must acknowledge diversities based on religion.

Although the current study found a significant association between the religions of HCPs and their overall perceptions of the four EDM-Cs, the adjusted median differences in the seven factors constituting the ethical climates were not statistically significant. When comparing nurses’ and physicians’ perceptions of their EDM-Cs (in another sub-study of the DISPROPRICUS study), substantially larger and statistically significant differences were found [7], suggesting that religion plays a role in connection with EDM-Cs but is not as dominant as other factors, such as profession.

The current study also indicates that non-religious HCPs in good climates perceive leadership among clinicians as more empowering and self-reflective compared to religious HCPs. This may suggest that discussions and reflections may be better fostered in ICUs dominated by non-religious HCPs, where the hierarchy may be less dominant, and the leader can be questioned without the HCPs being afraid of a reprimand. Likewise, the study indicates that differences of opinions are better tolerated in good climates.

The strengths of this study include the substantial number of multinational participants, inclusion of both physicians and nurses, and identification of factors and climates based on previously published comprehensive statistical analyses.

The study also has several limitations. The data came only from the Western hemisphere and are therefore only directly generalisable to Western countries. Participation from Asia, Middle East and Africa may have altered the findings and the conclusions, as seen in the ETHICUS-2 study [23]. The participating ICUs were included via network contacts, which may have introduced selection bias into the results. Furthermore, the effects of religion may be difficult to disentangle from the effects of cultural factors; although our results were adjusted for country, there may well be residual confounding. The analyses were based on the dichotomy of being religious or non-religious, which, in real life, probably includes more diverse variations, and identification with a specific faith may individually and culturally have different impacts in Europe and the US on conceptions of level of religiosity and on decision-making. Furthermore, the study only looked at all the main religions, but did not include a broader perception of spirituality. A final and important limitation is that no distinction was made between different religious affiliations. This study examined differences between the importance of religion for HCPs but did not contain distinctions between specific religions and their differing views on the EOL. Two literature reviews have found that religions have differing views on euthanasia and do-not-resuscitate orders [11, 24] and on what constitutes disproportionate treatment [24]. This study thus highlights that further research on religion in an ICU and EOL decision-making context should be concerned with specific religions and their differing values regarding the EOL.

Conclusion

Overall, ethical climate was associated with religious belief, with non-religious healthcare provides generally having a more positive perception of their ethical climate compared to religious healthcare providers.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

References

  1. Michalsen A, Long AC, DeKeyser Ganz F, White DB, Jensen HI, Metaxa V, et al. Interprofessional Shared decision-making in the ICU: a systematic review and recommendations from an Expert Panel. Crit Care Med. 2019;47:1258–66.

    Article  Google Scholar 

  2. Benoit DD, Jensen HI, Malmgren J, Metaxa V, Reyners AK, Darmon M, et al. Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA. Intensive Care Med. 2018;44:1039–49.

    Article  Google Scholar 

  3. Van den Bulcke B, Metaxa V, Reyners AK, Rusinova K, Jensen HI, Malmgren J, et al. Ethical climate and intention to leave among critical care clinicians: an observational study in 68 intensive care units across Europe and the United States. Intensive Care Med. 2020;46:46–56.

    Article  Google Scholar 

  4. Clark PG. Reflecting on reflection in interprofessional education: implications for theory and practice. J Interprof Care. 2009;23:213–23.

    Article  Google Scholar 

  5. Reader TW, Flin R, Cuthbertson BH. Team leadership in the intensive care unit: the perspective of specialists. Crit Care Med. 2011;39:1683–91.

    Article  Google Scholar 

  6. Van den Bulcke B, Piers R, Jensen HI, Malmgren J, Metaxa V, Reyners AK, et al. Ethical decision-making climate in the ICU: theoretical framework and validation of a self-assessment tool. BMJ Qual Saf. 2018;27:781–9.

    Article  Google Scholar 

  7. Jensen HI, Hebsgaard S, Hansen TCB, Johnsen RFA, Hartog CS, Soultati I, et al. Perceptions of ethical decision-making climate among clinicians Working in European and U.S. ICUs: differences between nurses and Physicians. Crit Care Med. 2019;47:1716–23.

    Article  Google Scholar 

  8. Silverman H, Wilson T, Tisherman S, Kheirbek R, Mukherjee T, Tabatabai A, et al. Ethical decision-making climate, moral distress, and intention to leave among ICU professionals in a tertiary academic hospital center. BMC Med Ethics. 2022;23:45.

    Article  Google Scholar 

  9. Donkers MA, Gilissen V, Candel M, van Dijk NM, Kling H, Heijnen-Panis R, et al. Moral distress and ethical climate in intensive care medicine during COVID-19: a nationwide study. BMC Med Ethics. 2021;22:73.

    Article  Google Scholar 

  10. Dodek PM, Wong H, Norena M, Ayas N, Reynolds SC, Keenan SP, et al. Moral distress in intensive care unit professionals is associated with profession, age, and years of experience. J Crit Care. 2016;31:178–82.

    Article  Google Scholar 

  11. Bulow HH, Sprung CL, Reinhart K, Prayag S, Du B, Armaganidis A, et al. The world’s major religions’ points of view on end-of-life decisions in the intensive care unit. Intensive Care Med. 2008;34:423–30.

    Article  Google Scholar 

  12. Bulow HH, Sprung CL, Baras M, Carmel S, Svantesson M, Benbenishty J, et al. Are religion and religiosity important to end-of-life decisions and patient autonomy in the ICU? The Ethicatt study. Intensive Care Med. 2012;38:1126–33.

    Article  Google Scholar 

  13. Moale A, Teply ML, Liu T, Singh AL, Basyal PS, Turnbull AE. Intensivists’ religiosity and Perceived Conflict during a simulated ICU family meeting. J Pain Symptom Manage. 2020;59:687–93. e1.

    Article  Google Scholar 

  14. Piers RD, Azoulay E, Ricou B, Dekeyser GF, Decruyenaere J, Max A, et al. Perceptions of appropriateness of care among European and Israeli intensive care unit nurses and physicians. JAMA. 2011;306:2694–703.

    Article  Google Scholar 

  15. Sexton JB, Helmreich RL, Neilands TB, Rowan K, Vella K, Boyden J, et al. The Safety attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res. 2006;6:44.

    Article  Google Scholar 

  16. Van den Bulcke B, Vyt A, Vanheule S, Hoste E, Decruyenaere J, Benoit D. The perceived quality of interprofessional teamwork in an intensive care unit: a single centre intervention study. J Interprof Care. 2016;30:301–8.

    Article  Google Scholar 

  17. Stogdill RM, Coons AE. Leadership behavior description questionnaire (LGDQ). Oxford England: Ohio State University; 957 1957.

  18. Vyt A. Interprofessional education and collaborative practice in health and social care: the need for transdisciplinary mindsets, instruments and mechanisms. In: Gibbs P, editor. Transdisciplinary professional learning and practice. Berin/Zug: Springer; 2016. pp. 69–88.

    Google Scholar 

  19. Kahn A. UCL - at the heart of multicultural London https://www.ucl.ac.uk/students/news/2020/dec/ucl-heart-multicultural-london2020 [.

  20. Yaguchi A, Truog RD, Curtis JR, Luce JM, Levy MM, Melot C, et al. International differences in end-of-life attitudes in the intensive care unit: results of a survey. Arch Intern Med. 2005;165:1970–5.

    Article  Google Scholar 

  21. Koh M, Hwee PC. End-of-life care in the intensive care unit: how Asia differs from the West. JAMA Intern Med. 2015;175:371–2.

    Article  Google Scholar 

  22. Almansour I, Abdel Razeq NM. Communicating prognostic information and hope to families of dying patients in intensive care units: a descriptive qualitative study. J Clin Nurs. 2021;30:861–73.

    Article  Google Scholar 

  23. Avidan A, Sprung CL, Schefold JC et al. Variations in end-of-life practices in intensive care units worldwide (Ethicus-2): a prospective observational study. Lancet Respir Med 2021:91101–20.

  24. Steinberg SM. Cultural and religious aspects of palliative care. Int J Crit Illn Inj Sci. 2011;1:154–6.

    Article  Google Scholar 

Download references

Acknowledgements

The authors thank all participating nurses and physicians. Likewise we would like to thank the national coordinators (please see affiliations below). Johan Malmgren, Victoria Metaxa, Anna K. Reyners, Katerina Rusinova, Danny Talmor, Anne-Pascale Meert, Laura Cancelliere, Laszlo Zubek, Paulo Mai, Andrej Michalsen and participating centers and local investigators: Participating centers and local investigators: Belgium: University Hospital, Vrije Universiteit Brussel, Brussels (Herbert Spapen, Marie-Claire Van Malderen, Godelieve Opdenacker), Leuven University Hospital, Leuven (Geert Meyfroidt, Dieter Mesotten, Joost Wauters, Marie Van Laer and Alexander Wilmer, Joost Wauters, Helga Ceunen), ZNA Stuivenberg, Antwerpen (Inneke E De Laet, Anita Jans), Ghent University Hospital, Gent (Dominique Benoit, Sandra Oeyen, Ingrid Herck, Stephanie Bracke, Charlotte Clauwaert), Institut Jules Bordet, Bruxelles (Meert Anne-Pascale, Leclercq Nathalie), CHU-Brugmann, Bruxelles (Devriendt Jacques), CHU Saint Pierre, Bruxelles (Dechamps Philippe), Czech Republic: Liberec District Hospital, Liberec (Ivana Zykova), Masaryk University, Brno and University Hospital, Brno (Jan Malaska), Third Faculty of Medicine, Charles University, Prague (Matous Schmidt), Hospital and Polyclinic Havirov, Havirov (Igor Satinsky), Institute for Experimental and Clinical Medicine, Prague (Eva Kieslichova), 3rd Medical Department, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague (Jarmila Krizova), Karlovy Vary District Hospital, Karlovy Vary (Robert Janda), Pardubice District Hospital, Pardubice (Magdalena Fortova, Jiri Matyas), First Faculty of Medicine, Charles University and General University Hospital, Prague (Katerina Rusinova, Ondrej Kopecky), Denmark: Herning Hospital, Herning (Christian Alves Køhler Pedersen), Kolding Hospital, Kolding (Stine Hebsgaard), Vejle Hospital, Vejle (Rikke Frank Aagaard Johnsen), Holbæk Hospital, Holbæk (Tina Charlotte Bitsch Hansen), France: Saint-Etienne University Hospital and Jacques Lisfranc Medical School, Saint-Etienne (Michael Darmon), Saint-Louis University Hospital, APHP, Université Paris-7, Paris (Danielle Reuter, Elie Azoulay), Institut Paoli Calmette, Marseilles (Djamel Mokart), Montfermeil Hospital, Montfermeil (François Vincent), Germany: University Hospital Jena, Jena (Christiane S. Hartog), Viersen General Hospital, Viersen (Peter Gretenkort), Tettnang Hospital, Tettnang (Andrej Michalsen), Greece: Agia Olga Hospital, Athens (Aikaterini Kounougeri), Evangelismos Hospital, Athens (Serafim Nanas), Agios Pavlos Hospital, Thessaloniki (Despina Papachristou), AHEPA University Hospital, Thessaloniki, (Ioanna Soultati), G.Gennimatas Hospital, Thessaloniki (Dimitrios Lathyris), Hippokratio General Hospital, Thessaloniki (Marili Pasakiotou), Papageorgiou General Hospital, Thessaloniki (Marina Oikonomou), Hungary: Semmelweis University Budapest, Budapest (Gábor Élő, Orsolya Szűcs), Kaposi Mór Teaching Hospital, Kaposvár University, Kaposvár (János Fogas), St. Stephen and St. Leslie Metropolitan Hospital, Budapest (Ilona Bobek), Italy: Azienda Ospedaliero Universitaria, “Maggiore della Carità”, Novara, and Department of Translational Medicine, Università del Piemonte Orientale, Novara (Francesco Della Corte, Carlo Olivieri, Rosanna Vaschetto, Laura Cancelliere), Ospedale Civile San Salvatore, and Department of Life, Health and Environmental Sciences (MeSVA), University of L’Aquila and Department of Emergency, San Salvatore Hospital, L’Aquila (Franco Marinangeli, Tullio Pozone, Alessandra Ciccozzi), The Netherlands: Canisius Wilhelmina Ziekenhuis, Nijmegen (A. Schouten, Monique Bruns), Medical Center Leeuwarden, Leeuwarden (Rik T. Gerritsen, Matty Koopmans), Erasmus University Hospital of Rotterdam (Erwin Kompanje, Ditty van Duijn), University of Groningen and University Medical Center Groningen, Groningen (Jan G. Zijlstra, Anne KL Reyners), Wilhelmina Ziekenhuis Assen, Assen (Johan G. Lutisan), Portugal: Hospital S.António, Porto (Raquel Monte, José António Pinho, Pedro Pimenta), CHVNG, Vila Nova de Gaia (Paula Fernandes, Ana Isabel Paixão), Instituto Português de Oncologia, Porto (Filomena Faria), Sweden: Sahlgrenska University Hospital, Gothenburg (Johan A. Malmgren), Sahlgrenska University Hospital/Östra, Gothenburg (Bertil Andersson), Skåne University Hospital, Malmö (Eva Åkerman), Karolinska University Hospital, Karolinska (Andreas Hvarfner), The Hospital of Norrköping, Norrköping (Robert Svensson), United Kingdom: King’s College Hospital, London (Victoria Metaxa), USA: Beth Israel Deaconess Medical Center and Harvard Medical School, Boston MA (Daniel Talmor, Ariel Mueller, Valerie Banner-Goodspeed), Henry Mayo Newhall Memorial Hospital, Valencia, CA (Dee Rickett), Mayo Clinic, Rochester, MN (Michael E. Wilson, Richard Hinds).

Funding

Open access funding provided by University of Southern Denmark

The study was supported by the European Society of Intensive Care medicine/European Critical care research network clinical research, a Fonds voor Wetenschappelijk Onderzoek senior clinical investigators grant (1800513 N) and by Fund Marie-Thérèse De Lava, King Baudouin Foundation, Belgium.

Author information

Authors and Affiliations

  1. Departments of Anaesthesiology and Intensive Care, Vejle Hospital, University Hospital of Southern Denmark, Beriderbakken 4, Vejle, 7100, Denmark

    Hanne Irene Jensen

  2. Department of Anaesthesiology and Intensive Care, Kolding Hospital, University Hospital of Southern Denmark, Sygehusvej 24, Kolding, 6000, Denmark

    Hanne Irene Jensen

  3. Institute of Regional Health Research, University of Southern Denmark, J.B.Winsløwsvej 19, Odense, 5000, Denmark

    Hanne Irene Jensen

  4. Department of Anaesthesiology and Intensive Care, Holbaek Hospital, Smedelundsgade 60, Holbaek, 4300, Denmark

    Hans-Henrik Bülow

  5. Department of Marketing, Innovation and Organisation, Ghent University, Tweekerkenstraat 2, Ghent, 9000, Belgium

    Lucas Dierickx

  6. Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Krijgslaan 281, S9, Ghent, 9000, Belgium

    Stijn Vansteelandt

  7. University of Eastern Piedmont, Via Solaroli 17, Novara, 28100, Italy

    Rosanna Vaschetto

  8. Semmelweis University, Üllői út 26, Budapest, 1085, Hungary

    Gábor Élö

  9. Department of Geriatrics, Ghent University Hospital and Ghent University, Corneel Heymanslaan 10, Ghent, 9000, Belgium

    Ruth Piers

  10. Department of Intensive Care Medicine, Ghent University Hospital and Ghent University, Corneel Heymanslaan 10, Ghent, 9000, Belgium

    Dominique D. Benoit

Authors
  1. Hanne Irene Jensen
    View author publications

    You can also search for this author inPubMed Google Scholar

  2. Hans-Henrik Bülow
    View author publications

    You can also search for this author inPubMed Google Scholar

  3. Lucas Dierickx
    View author publications

    You can also search for this author inPubMed Google Scholar

  4. Stijn Vansteelandt
    View author publications

    You can also search for this author inPubMed Google Scholar

  5. Rosanna Vaschetto
    View author publications

    You can also search for this author inPubMed Google Scholar

  6. Gábor Élö
    View author publications

    You can also search for this author inPubMed Google Scholar

  7. Ruth Piers
    View author publications

    You can also search for this author inPubMed Google Scholar

  8. Dominique D. Benoit
    View author publications

    You can also search for this author inPubMed Google Scholar

Contributions

Study concept and design: RP, DB. Design of the questionnaire: DB, HIJ, RP. Acquisition ofdata: DB, HIJ, HHB, RV, GÈ. Analysis and interpretation of data: LD, SV, HIJ, HHB, RP, DB. Drafting of the manuscript: HIJ, HHB, LD, SV, DB, RP. Critical revision of the manuscript for important intellectual content: HIJ, HHB, LD, SV, RV, GÈ, RP, DB. Accept of final version: HIJ, HHB, LD, SV, RV, GÈ, RP, DB.

Corresponding author

Correspondence to Hanne Irene Jensen.

Ethics declarations

Ethics approval and consent to participate

The study was conducted in accordance to national guidelines and regulations and in accordance to the Declaration of Helsinki. The study was approved by the ethics committees of all participating centers and the Danish National Health Authority. All clinical participants received written and oral information about the study. Participation was voluntary, and the local investigators did not have access to the individual responses. The participants provided informed consent by filling in the questionnaire.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Supplementary Material 2

Supplementary Material 3

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Jensen, H.I., Bülow, HH., Dierickx, L. et al. Perceptions of ethical decision-making climate among clinicians working in European and US ICUs: differences between religious and non-religious healthcare professionals. BMC Med Ethics 26, 21 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12910-025-01178-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12910-025-01178-5

Keywords

BMC Medical Ethics

ISSN: 1472-6939

Contact us