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This study examines ethical decision-making among physicians within the evolving Tunisian healthcare context,
marked by rising healthcare expenditures, structural transitions, and the disruptive effects of the COVID-19
pandemic. Ethical challenges in medical practice are amplified by the complexity of patient–provider
interactions, the urgency of clinical decisions, and the sociocultural environment in which practitioners operate.
While international literature provides extensive insights into ethics in marketing and management, empirical
research focusing on medical ethics, particularly in North African contexts, remains limited. To address this gap,
a qualitative exploratory study was conducted with 11 physicians representing diverse specialties, sectors, and
professional backgrounds. Semi-structured interviews were analyzed through thematic content analysis to
identify the variables influencing ethical decision-making. The findings reveal that medical ethics is perceived
as a set of intrinsic values guiding physicians in navigating dilemmas under time-sensitive and high-stakes
conditions. Two overarching categories of determinants emerged. Individual variables include academic
background, experience, religiosity, personal values, socioeconomic conditions, emotional states, moral power,
and all dimensions of moral intensity. Situational variables encompass professional dynamics such as peer
support and interpersonal relationships, organizational resources and culture, and external influences including
patients, families, social norms, and the judicial and industrial environments. Several novel factors, particularly
personal values, socioeconomic pressures, organizational resource constraints, and judicial influence, highlight
the specificity of the Tunisian context. The study contributes a contextualized framework for understanding
ethical decision-making among healthcare providers. It offers practical implications for communication
strategies, organizational leadership, and ethical governance, while emphasizing the need for future quantitative
investigations to validate and extend these findings.
Ethics, ethical decision-making, organizational environment, professional environment, external
environment, healthcare transformation, medical ethics.
Healthcare has become one of the most economically and socially significant service sectors worldwide, with
direct implications for marketing theory and practice. Between 2012 and 2020, nearly one billion individuals
devoted more than 10% of their household budget to healthcare expenditures, while over 300 million spent more
than 25%, reflecting a substantial and growing financial burden on consumers (WHO, 2022). Globally,
healthcare spending now represents approximately 10% of gross domestic product and continues to grow at a
rate exceeding overall economic growth. This trend is particularly pronounced in low- and middle-income
countries, where healthcare expenditures have increased at a faster pace than in high-income economies (WHO,
2019). Tunisia exemplifies this dynamic, with per capita healthcare spending rising markedly over recent years,
highlighting the growing centrality of healthcare services within household consumption and national
economies.
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From a marketing perspective, these developments reposition healthcare not merely as a public good, but as a
high-involvement, high-risk service characterized by intense interactions, strong information asymmetries, and
profound ethical implications. The COVID-19 pandemic further accentuated these characteristics by disrupting
service delivery systems, amplifying uncertainty, and intensifying consumers’ reliance on professional judgment
(Diogo & Veiga, 2022). In Tunisia, these effects were compounded by a broader post-2011 political and
institutional transformation, often described as a “Healthcare Renaissance,” which has reshaped public
expectations, trust relationships, and value perceptions in healthcare services. This context raises fundamental
questions within marketing scholarships about ethical value creation, trust, and responsibility in service
exchanges. Recent research has emphasized that periods of systemic disruption influence consumer ethics and
challenge the normative foundations of marketing practice (He & Harris, 2020). These challenges are particularly
salient in healthcare services, which represent one of the most complex forms of service delivery due to the
intensity of relational interactions, the credence nature of the service, and the asymmetry of expertise between
service providers and consumers (Briscoe et al., 2012). In such contexts, ethical dilemmas frequently emerge,
and their resolution depends largely on the discretionary decisions of frontline service providers, namely
physicians, whose judgments directly affect service outcomes, perceived fairness, and patient trust (Tønnessen
et al., 2017).
Despite the growing recognition of ethics as a central concern in marketing and management research (McDevitt,
2007; Heyler et al., 2016; He & Harris, 2020), empirical studies addressing ethical decision-making in healthcare
services from a marketing perspective remain limited. Existing marketing ethics research has predominantly
focused on corporate behavior, branding, or consumer responses, while largely overlooking physicians as
frontline service employees embedded in complex service ecosystems. Only a small number of studies have
explicitly examined ethical decision-making among physicians by conceptualizing them as providers of
professional services operating under relational, organizational, and institutional constraints (e.g., Deshpande et
al., 2009; Zyung et al., 2020). Yet, recent marketing scholarship increasingly calls for the development of
integrative models that account for ethical behavior within service systems, particularly in high-stakes sectors
such as healthcare (Abrantes et al., 2022).
Given the non-hypothetical nature of medical services, where decisions have immediate and sometimes
irreversible consequences (Kreitmair, 2021), understanding ethical decision-making among physicians is critical
not only from a clinical standpoint but also from a marketing and service management perspective. Ethical
decisions made by physicians influence perceived service quality, relational trust, patient satisfaction, and
ultimately the legitimacy of healthcare institutions. However, existing studies tend to emphasize either individual
moral reasoning or abstract ethical principles, without sufficiently accounting for the interaction between
individual characteristics and situational factors embedded in the service environment.
In response to these gaps, the present study aims to advance services marketing and marketing ethics research
by examining ethical decision-making among physicians, who serve as frontline healthcare service providers
within a complex service ecosystem. Adopting a qualitative approach, this research examines how individual
characteristics, organizational conditions, and broader systemic constraints collectively influence ethical
judgments and actions in clinical service encounters. Accordingly, the study addresses the following research
question: How do individual, organizational, and systemic factors influence ethical decision-making among
physicians as frontline healthcare service providers? By answering this question in the Tunisian healthcare
context, the study contributes a context-sensitive and multilevel framework that enhances understanding of
ethical value creation, trust, and professional conduct in high-stakes service environments.
To use Reverdy's (1948) terms, ethics represents "inner aesthetics." Numerous complementary definitions exist
to ensure a better understanding of this notion. A thorough literature review has identified two main categories
of definitions. The first apprehend ethics as a process. Indeed, ethics is a continuous process or reflection based
on moral principles to perform actions accepted by society (World Medical Association, 2015; Costa, 1998;
Gossling, 2003; Pope & Vasquez, 1998; Richard, 2011; Strike & Soltis, 1985). The second category presents
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ethics based on the notion of regulation. From this perspective, ethics is treated based on its regulatory nature
(Boisvert & Bégin, 2019; Boyer, 2004; Giasson, 2020). Summarizing these perspectives, it is possible to advance
that ethics is an active reflection process based on regulation to determine acceptable individual and collective
behaviors.
According to the World Medical Association (2015), medical ethics is primarily concerned with problems raised
by the practice of medicine. It is the application of ethical reasoning to medical decision-making. The modern
use of the term medical ethics dates back to 1803 with Thomas Percival's introduction of a document describing
the requirements and expectations of health professionals within medical establishments. It was based on his
thoughts that the code of ethics was adopted in 1847. Subsequently, medical ethics materialized by universal
codes and declarations, notably the Nuremberg Code in 1946. In practice, medical ethics is a critical reflection
on "norms or values, good or bad, and what should or should not be done in the context of medical practice"
(Gillon, 1985). More precisely, it aims to resolve conflicts between values, law, and concurrent obligations (Ben
Amor, 2015).
While general and medical ethics are foundational, the process of ethical decision-making is crucial, defined as
"the process by which individuals determine whether an action is right or wrong based on their moral references"
(Carlson et al., 2009). Traditional literature frames ethical decision-making as a combination of individual moral
development (Rest, 1986), moral intensity components (Jones, 1991), and situational factors (Ferrell & Gresham,
1985; Hunt & Vitell, 1986). These traditional cognitive rational models viewed decision-making as conscious
and controlled.
However, recent developments in literature have significantly expanded this view. Researchers have increasingly
integrated unconscious and uncontrolled variables, such as emotions and affect, into the ethical decision-making
process (Heyler et al., 2016; Li et al., 2020). The post-2020 healthcare landscape, profoundly shaped by the
COVID-19 pandemic, has introduced new layers of complexity. The pandemic forced physicians to navigate
unprecedented ethical dilemmas regarding resource allocation, triage, and duty of care under risk, often in
environments characterized by high moral distress.
A critical emerging factor in this modern context is the dynamic of trust and communication between provider
and patient. Recent research highlights that the patient-physician relationship is foundational to ethical outcomes.
Trust is a pivotal element in how patients perceive communication and its influence on ethical decision-making
(Ben Amor et al., 2025a). Effective communication is not merely a clinical tool but an ethical imperative that
shapes the trust necessary for shared decision-making (Ben Amor et al., 2025a). Furthermore, the cultural and
religious context cannot be overlooked, especially in the MENA region. The interplay between religious beliefs
and market/service interactions is profound. In their extensive review, Religious underpinnings significantly
influence consumer (patient) expectations and provider behaviors. This suggests that ethical decision-making in
the Tunisian context must account for these deep-seated cultural and religious variables (Ben Amor et al., 2025b).
Additionally, the organizational climate has been identified as a determinant factor. Silverman et al. (2022)
emphasize that the ethical decision-making climate within healthcare institutions directly correlates with moral
distress levels among professionals. When the organizational environment supports ethical deliberation,
physicians are better equipped to handle high-intensity moral situations.
Consequently, the variables influencing ethical decision-making can be categorized into:
Individual profile (McDevitt et al., 2007; Abrantes et al., 2022), moral intensity (Jones,
1991), moral power (Heyler et al., 2016), and emotions (Li et al., 2020).
Organizational environment (Treviño et al., 2003; Silverman et al., 2022),
professional environment (Treviño, 1986), and external environment (McDevitt, 2007; Ben Amor et al.,
2025b).
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This study seeks to develop an understanding of ethical decision-making among Tunisian medical service
providers. In other words, we aim to identify both the individual and situational variables involved in physicians’
ethical decision-making, which are therefore essential to the process of ethical deliberation.
To achieve this, an exploratory qualitative study was conducted using individual semi-structured interviews with
physicians, following an interview guide provided in the appendix. This methodological choice appeared most
appropriate, as this type of interview allows direct contact with the interviewee, leading to a deeper
understanding of their experience. Moreover, it provides access to explanations deeply embedded in participants’
minds—elements that are rarely expressed in group settings or through standard questionnaires (Auger-Aubin et
al., 2021). Semi-structured questions also make it possible to organize respondents’ thoughts thematically while
offering flexibility in their answers, enabling them to express their values, beliefs, representations, and
underlying convictions. As noted by Quivy and Campenhoudt (1995), “the semi-structured interview is neither
completely open nor strictly controlled by numerous precise questions. A grid of themes is used, with relatively
open guiding questions.” To test the interview guide and ensure more effective management of the interviews, a
pre-test was conducted with a resident, a physician, and a clinical research associate. This pre-test allowed us to
identify and correct imperfections by adding, removing, or modifying questions.
Since the purpose of qualitative research is to ensure richness, depth, and content quality rather than a statistically
representative sample, the physicians were selected to maximize diversity in gender, age, sector, and specialty.
The final sample consists of 11 physicians, whose characteristics appear in Table 1. The number of interviewees
followed the saturation principle, whereby data collection ends once new information ceases to emerge and
responses become repetitive. Interview durations ranged from 43 minutes to 1 hour and 20 minutes. Ethical
standards regarding confidentiality and the use of personal data were strictly observed.
All interviews were transcribed manually and automatically using AI-based transcription software to optimize
the transcription process and minimize human error.
In1
30
7 years
Ophthalmologist
Private
In2
25
1 year
Radiologist
Public
In3
48
18 years
Dentist
Public
In4
49
24 years
Forensic Doctor
Public
In5
68
40 years
Dentist
Private
In6
82
33 years
General Practitioner
Public
In7
60
17 years
Physiologist
Public
51
5 years
Intensive Care
Private
30
5 years
Intensive Care
Public
30
5 years
Ophthalmologist
Public
30
5 years
Cardiovascular Surgeon
Public
This study examined how Tunisian physicians perceive and navigate ethical decision-making in clinical practice.
The thematic analysis revealed four overarching domains: conceptualizations of medical ethics, ethical dilemmas
encountered in clinical settings, individual determinants influencing ethical decisions, and situational
determinants shaping their reasoning and actions.
Participants expressed diverse and sometimes conflicting interpretations of what constitutes medical ethics. For
some, ethics reflected a set of professional virtues that guide the physician’s moral character and interactions
with patients. As one participant explained, “Ethics means respecting the patient and being human above all”
(R1). Others adopted a more normative perspective, viewing ethics through the lens of legal and deontological
In8
In9
In10
In11
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compliance—“We follow the code… We must do what the law and the deontology require” (R7). A third group
conceptualized ethics as a contextual and dynamic reasoning process that depends on the particularities of each
clinical situation, noting that “Ethics depends on each situation; you have to think quickly according to the
context” (R12). Overall, these perspectives indicate that ethical decision-making relies heavily on rapid, context-
driven judgment rather than on the application of abstract principles.
Physicians described a wide range of ethical dilemmas that recur in daily medical practice. Decisions related to
the limitation or withdrawal of futile care were described as particularly distressing, with one respondent stating,
“There are cases where we know that prolonging care is useless. It is very difficult” (R4). Medication shortages
further complicated ethical practice, leading some physicians to make improvised decisions they considered
morally problematic, as reflected in the statement, “Sometimes we do not have the medication… We have to
improvise, and that is not ethical” (R15). Systemic pressure and patient flow, especially in emergency settings,
created ethically charged environments in which rapid decisions were often unavoidable: “We work under
pressure… you must make a quick decision even if it is not the most ethical one” (R18). Communication
challenges were also evident, with several physicians acknowledging that time constraints often prevented
adequate dialogue with patients: “We do not always have the time to explain. It is not ideal but it is the reality”
(R22). Maintaining confidentiality was another difficulty, particularly in crowded or resource-limited settings,
where “Medical secrecy is difficult to respect when everyone wants to know” (R29). Additional tensions arose
from interactions with pharmaceutical companies—“Pharmaceutical companies sometimes push… We must
remain vigilant not to deviate” (R17)—as well as from dealing with vulnerable patients who heightened the
emotional burden of decisions: “When the patient is vulnerable, the decision becomes morally heavier” (R35).
Individual determinants also played a central role in shaping ethical decision-making. Participants noted that
academic training and clinical experience mattered, but many emphasized the role of personal upbringing and
family values, as illustrated by the statement, “Training matters, but it is mostly the values you received at home”
(R11). Socioeconomic conditions were also cited as influencing ethical behaviour, sometimes in subtle and
unintended ways: “The living conditions of the doctor matter… sometimes we are influenced despite ourselves”
(R31). Emotional experiences—including fear, empathy, stress, and frustration—significantly affected
physicians’ ethical sensitivity and judgement. One respondent noted, “The fear of making a mistake greatly
influences our choices” (R20). Moral intensity further conditioned their decisions, as severe consequences
prompted more cautious deliberation, expressed in the statement, “When the consequences are serious, you
weigh every word and every gesture” (R14). Moral power, or the perceived ability to act autonomously, also
varied with seniority, with younger physicians reporting limited authority to implement the decisions they
deemed ethically appropriate: “When you are young, you do not always have the power to do what you think is
right” (R26).
Finally, situational determinants significantly shaped ethical decision-making. Organizational constraints—
including limited resources, inadequate workflows, and weak administrative structures—were frequently cited
as barriers, with one respondent noting, “The problem is not the willingness, it is the organization that blocks
us” (R33). External environmental factors such as health policies, insurance procedures, and market shortages
imposed additional limits on physicians’ ethical options, as reflected in the remark, “Reimbursement rules
complicate everything… this affects our decisions” (R24). Professional norms and hierarchical structures also
had a strong influence, particularly in settings where decisions were shaped by senior physicians’ preferences,
sometimes overriding individual ethical judgment. As one participant reported, “Sometimes we think differently,
but we follow the head of the department” (R8).
This study contributes to the marketing literature by conceptualizing ethical decision-making in healthcare
services as a multilevel process shaped by the interaction of individual, organizational, and sociocultural
determinants. While ethical decision-making has been widely examined in marketing and business contexts,
particularly in relation to consumer trust, service quality, and professional conduct, empirical insights from
healthcare services in emerging economies remain limited. By focusing on physicians as frontline service
providers, this research extends services marketing theory by demonstrating how ethical behavior is co-produced
under conditions of emotional labor, organizational constraints, and systemic pressures.
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At the individual level, the findings highlight the role of personal values, professional experience, emotions, and
perceived moral autonomy in shaping ethical judgments. These results align with marketing ethics research
emphasizing moral philosophy, individual values, and ethical sensitivity as antecedents of ethical decision-
making (Hunt & Vitell, 1986; Ferrell et al., 2019). The strong influence of emotions such as stress, fear, and
empathy supports recent work in services marketing that positions frontline employees’ emotional labor as a
critical driver of ethical and service-related outcomes (Bolton et al., 2018). In healthcare marketing, where
service encounters are high in credence attributes and emotional intensity, ethical decisions become inseparable
from relational and experiential dimensions of service delivery.
However, individual ethical intentions were frequently constrained by organizational-level factors, including
time pressure, resource scarcity, performance demands, and hierarchical structures. This finding resonates with
marketing studies showing that organizational culture, control systems, and managerial pressure significantly
shape ethical behavior among service employees (Trevino et al., 2014). In highly institutionalized service
contexts such as healthcare, organizational constraints not only limit available choices but also redefine what is
perceived as ethically acceptable behavior. Junior physicians’ reduced moral power mirrors findings in services
marketing where role ambiguity and power asymmetry weaken employees’ capacity to enact ethical service
behaviors, even when ethical awareness is high.
At the sociocultural and systemic level, national health policies, reimbursement mechanisms, and medication
availability influenced service delivery decisions and ethical trade-offs. From a marketing perspective, these
macro-level factors shape the service ecosystem in which value is created and delivered. Recent service-
dominant logic literature emphasizes that value co-creation is embedded within institutional arrangements and
resource integration mechanisms that extend beyond firm-level control (Vargo & Lusch, 2016). The ethical
dilemmas identified in this study—particularly those related to access, fairness, and transparency—reflect
tensions within the healthcare service ecosystem, where institutional constraints directly affect perceived service
equity and trust.
Crucially, the findings demonstrate that ethical dilemmas emerge most intensely at the intersection of these three
levels. High moral intensity situations—such as caring for vulnerable patients under severe time and resource
constraints—simultaneously increased ethical sensitivity while reducing ethical agency. This interaction helps
explain inconsistencies observed in marketing ethics research between ethical intentions and actual behavior
(Ferrell et al., 2019). In healthcare services, where consumers rely heavily on professional expertise and trust,
such discrepancies may have significant implications for perceived service quality, relational trust, and
institutional legitimacy.
From a theoretical standpoint, this study advances marketing ethics research by integrating multilevel dynamics
into ethical decision-making models, which have traditionally emphasized individual cognition and moral
philosophy. By incorporating organizational and ecosystem-level constraints, the findings support calls for more
context-sensitive and system-oriented approaches in services marketing ethics. Practically, the results suggest
that improving ethical behavior in healthcare services requires interventions beyond individual ethics training.
Organizational policies, leadership practices, and system-level reforms must align to support ethical service
delivery and sustain consumer trust. Overall, this study positions ethical decision-making as a core component
of healthcare service marketing, influencing patient trust, perceived service fairness, and relational value.
Recognizing ethical decision-making as a systemic and relational process provides a more realistic and
actionable foundation for both marketing theory and healthcare service management.
This study explored how physicians in Tunisia perceive and navigate ethical decision-making in clinical practice.
The findings demonstrate that ethical judgment is shaped by an interplay of professional values, contextual
constraints, and individual lived experiences. Physicians conceptualize ethics in diverse ways, ranging from
virtue-based and deontological approaches to situational reasoning, which reflects the multidimensional nature
of ethical deliberation in real clinical environments. The study also highlights several recurrent ethical dilemmas,
including medication shortages, time pressures, patient vulnerability, and systemic limitations that frequently
challenge the implementation of ethical principles.
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Moreover, personal factors such as upbringing, clinical experience, emotional states, and socioeconomic
conditions further contribute to the complexity of ethical behavior. Finally, organizational, professional, and
external environments substantially influence ethical choices, often acting as structural barriers to ideal ethical
practice. Overall, the findings suggest that ethical decision-making in the Tunisian healthcare context is less a
function of insufficient ethical knowledge than of complex contextual realities. Enhancing ethical practice,
therefore, requires a systemic approach—one that integrates institutional support, improved resource availability,
organizational reforms, and sustained professional development. Strengthening interprofessional
communication and promoting a culture of shared ethical responsibility may further help align clinical decisions
with ethical standards.
Significantly, this study brought to light new variables: the provider's personal values, socioeconomic situation,
organizational resources, the judicial system, patient/family influence, and industry influence. These results
establish a new research framework for medical service providers in Tunisia. Practically, these variables can
inform operational marketing, specifically communication strategies that focus on human aspects, respect for
cultural specificity (Ben Amor et al., 2025b), and ethical commitment. Strategically, executive leadership should
reflect a culture of ethical values (Silverman et al., 2022).
Despite its contributions, this study has several limitations that should be acknowledged. First, the qualitative
design and sample size, although adequate for thematic saturation, limit the generalizability of the findings to all
physicians in Tunisia or other healthcare systems. The perspectives reflect the experiences of the sampled
practitioners and may not capture the full diversity of ethical challenges across specialties, regions, or
institutional types. Second, data were based on self-reported perceptions, which may be subject to recall bias or
social desirability bias, particularly given the sensitivity of ethical topics. Third, the study did not include
observations of real-time clinical interactions; consequently, the analysis reflects perceived rather than directly
observed ethical behavior. Fourth, although the study highlights the importance of structural and systemic
factors, it does not quantitatively measure their relative impact, which limits the ability to compare the weight
of individual versus contextual determinants. Finally, the research was conducted within a specific national
healthcare system, and contextual specificities may limit the transferability of the findings to other sociocultural
and institutional environments.
Future research could build on these findings in several ways. First, quantitative studies could assess the
prevalence and relative weight of the identified determinants to provide a more precise understanding of how
individual, organizational, and systemic factors shape ethical decision-making. Second, a mixed-methods design,
including direct observations, ethnographic approaches, or simulated scenarios, could complement self-reported
data and capture ethical decision processes as they unfold in real time. Third, comparative studies across regions
or countries with differing healthcare infrastructures could help determine which ethical challenges are context-
specific and which reflect universal patterns in medical practice. Fourth, further investigation into the role of
emotions, moral intensity, and moral power could enrich theoretical models of clinical ethics by integrating
psychological and sociocultural perspectives. Finally, intervention-based research, such as training programs,
ethics rounds, or organizational policy reforms, could evaluate which strategies most effectively foster ethical
behavior and support physicians in morally complex environments.
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