hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh Original Article Copyright © 2023 Tehran University of Medical Sciences. This work is licensed under a Creative Commons Attribution-Non Commercial 4.0 International license https://creativecommons.org/licenses/by-nc/4.0/). Non-commercial uses of the work are permitted, provided the original work is properly cited. Abstract The concept of common morality is fundamental in medical ethics, and lack of universal content and characteristics of common morality is a product of its multifaceted nature. This study aimed to identify the ideas and experiences of academic faculties regarding common morality in a pluralistic setting to promote conceptual knowledge and strengthen moral reasoning and ethical decision-making. The study was conducted using a qualitative method, employing semi-structured in-depth interviews with thirteen faculty members who were selected purposively. In order to assess their ideas and experiences, the transcripts of the interviews were analyzed using the content analysis method through directed and conventional approaches. The interviews were coded manually. Two themes were reflected in the interviews: ontology and epistemology of common morality. The study indicates that the debate about the subjective or objective dependence of common morality questions the coherence of Beauchamp and Childress' common morality (CM) theory, as common morality is the result of various individual and social factor that influence moral and *Corresponding Author Bagher Larijani Address: Shariati Hospital, North Kargar Ave., Jalal-e-Al-e-Ahmad Hwy., Tehran, Iran. Postal Code: 1411713135 Tel: (+98) 21 88 63 12 97 Email: larijanib@tums.ac.ir Received: 10 Aug 2022 Accepted: 1 May 2023 Published: 19 Jun 2023 Citation to this article: Zahedi L, Larijani B, Javadi M, Aawani S, Jafari SA, Joodaki K, et al. A dialog on common morality in medical ethics in a pluralist setting in Iran: a qualitative content analysis. J Med Ethics Hist Med. 20232; 16: 3. decision -making in pluralistic environments. Additional studies are needed in order to investigate the effect of cultural, social, theoretical, ideological and individual factors on promoting clinical ethical reasoning and decision-making skills. Keywords: Principle-based ethics; Common morality; Clinical reasoning; Cultural diversity; Qualitative research. A dialog on common morality in medical ethics in a pluralist setting in Iran: a qualitative content analysis 1. PhD Candidate in Medical Ethics, Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran; Faculty Member of Iranian Academy of Medical Sciences, Tehran, Iran. 2. Professor, Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran. 3. Professor, Ethics Department, University of Qom, Qom, Iran. 4. Associate Professor, Iranian Research Institute of Philosophy (IRIP), Tehran, Iran. 5. Associate Professor, Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran. 6. PhD in Medical Ethics, Member of National Association of Iranian Obstetricians and Gynecologists (NAIGO), Tehran, Iran. 7. PhD in Medical Ethics, Head of Medical Error Committee, Shahriar Medical Council, Tehran, Iran. 8. Assistant Professor, Ethics Department, Iran University of Medical Sciences, Tehran, Iran. Ladannaz Zahedi1, Bagher Larijani2*, Mohsen Javadi3, Shahin Aawani4, Seyed Abdosaleh Jafari5, Kobra Joodaki6, Roya Rashidpouraie7, Saeedeh Saeedi Tehrani8 A dialog on common morality in medical ethics in a pluralist setting in Iran J. Med. Ethics. Hist. Med. 2023 (Jun); 16: 3. 2 Introduction Common Morality (CM) is a concept claiming that there exists a set of universal norms shared by all morally committed individuals. This basic concept plays a prominent role in medical ethics and ethical decision-making, and is the fundamental justification for Beauchamp and Childress' CM theory, which includes moral judgments in the medical arena. This theory implies that CM has realistic content; however, the existence and subjective independence of CM is disputed (1, 2). As moral universalists, Beauchamp and Childress attribute mind-independent properties to CM and consider morality as a reality detached from human knowledge (3). They claim that CM is not relativistic to cultures or peoples. In contrast, other researchers believe that cultural, social and psychological foundations argue for the non- universal conceptualization of morality (4 - 6). As moral relativists, the second group relies on the empirical doctrine that reality exists only within human knowledge and that reality is an object of knowledge relative to the conscious subject (7). Relativists relate the fallibility and provisional nature of solutions to ethical dilemmas to the hermeneutic aspect of moral reasoning (8). Beauchamp and Childress state that coherence and practicality should be part of the criteria for evaluating ethical theories. Theories should not contain conceptual inconsistencies or contradictory propositions. Their practical requirements are unacceptable if they are too high to be met (9). Beauchamp and Childress base their CM theory on Rawls’ reflective equilibrium to achieve coherence. They ground CM on four principles of autonomy, beneficence, non- maleficence and justice to achieve harmonious solutions to moral dilemmas while maintaining practicality (10). These principles are essential in the decision-making process when dealing with complex ethical dilemmas. For the decision-making process to be coherent and coordinated, well-considered judgments are required in moral reasoning. When conflicting arguments arise, balancing and specification help achieve the primary goal of coherence. The wide reflective equilibrium approach facilitates the examination of the solutions to ethical problems by integrating basic ethical principles with the ethical paradigm of the context in which they arise; the role and competence of the moral agent are also effective in this approach. Zahedi L., et al. 3 J. Med. Ethics. Hist. Med. 2023 (Jun); 16: 3. Some scholars claim that the neutrality of moral agents and freedom from bias are unrealistic ideals that may make the CM theory less practical (11). When the CM theory is introduced to normative issues, problems with coherence and practicality arise because the CM theory ignores the role of the moral agent who interprets and applies the principles. Therefore, it appears that the CM theory may not be a suitable guide for practitioners because it does not provide a practical tool for analyzing ethical issues (12, 13). The reason for this is that the cognitive mechanism of the moral agent, which is affected by his/her values, desires, motivations, and social and interpersonal relationships, is the central pillar of medical decision-making approaches (14). The pluralistic process of CM decision-making highlights the shortcomings of the CM theory in the realistic realm. To date, few studies have been conducted on the perspectives and experiences of pluralistic academic faculties regarding CM. A detailed explanation of the multiple aspects of the CM theory will help resolve the debate about the subjective and objective dependence of CM and enhance the reasoning and ethical decision- making skills of medical ethicists. Therefore, this research was designed to investigate the opinions and experiences of faculty members about CM in pluralistic settings. Methods Qualitative Approach and Research Paradigm This exploratory study was conducted from April 2018 to September 2019 through separate face-to- face interviews with faculty members of six academic faculties and research centers in Tehran. The naturalistic paradigm in which the subjects are observed in their natural environment was chosen because it helped the interviewers to better understand the content and meaning of the interviewees’ responses. The research team agreed to use directed and conventional approaches and not to use the summative method in order to avoid over-reliance on the quantification of the manifest content (pure lexical meaning cannot reveal latent meanings). Similarly, counting the frequency of codes increases the risk of overlooking content because the same word may be repeated for various reasons. Directed content analysis analyzes participants' perspectives and begins with a theory or relevant research findings as a guide for initial codes. This study started with the directed approach, and the questionnaire guide was created based on a narrative review. However, conventional content A dialog on common morality in medical ethics in a pluralist setting in Iran J. Med. Ethics. Hist. Med. 2023 (Jun); 16: 3. 4 analysis analyzes participants’ experiences, and therefore coding categories are extracted directly from the transcribed textual data (15 - 17). Researcher Characteristics and Reflexivity Five of the eight members of the research team were women. During the study, LZ was an M.D. and a Ph.D. candidate in Medical Ethics. BL, MJ, SA, SAJ and SST were faculty members of local universities and research centers. KJ was a member of the National Association of Iranian Gynecologists and Obstetricians (NAIGO), and RR was a member of the local Medical Council. LZ conducted the interviews, and all researchers carried out each stage of the study. This research sought faculty members' perspectives on CM content and CM-based experiences in decision- making when faced with ethical dilemmas, and the findings may expand relevant literature. Context and Sampling Strategy The study population consisted of 13 faculty members from five fields (medicine, medical ethics, philosophy, theology and sociology) in six academic faculties and research centers in Tehran. This ensured the diversity of the informants using a purposeful snowball sampling method. Eligible participants met the following criteria: 1) being faculty members of universities, research centers and institutes, scientific associations, and medical councils; 2) being interested in medical ethics, and 3) having deep opinions and experiences regarding the subject under study. Data collection continued until saturation, which was achieved after the initial ten interviews. Nevertheless, three additional interviews were performed for confirmation. Ethical Issues Pertaining to Human Subjects The participants were told about the interviewer and the purpose of the study, and were assured that they could cease participation at any time. The recording of the interviews started after obtaining their consent. Data confidentiality was ensured by restricting data access to the principal researcher and the study supervisor, and written informed consent was obtained from all participants. Ethical approval was obtained from the Research Ethics Committee of Tehran University of Medical Sciences (code number: IR.TUMS.REC.1395.2627). Data Collection Semi-structured in-depth interviews were used to collect data. The interviews lasted an average of 75 minutes and were held at the time and location chosen by each participant. When most of the quotes or initial codes became increasingly repetitive, data collection and analysis were stopped. Zahedi L., et al. 5 J. Med. Ethics. Hist. Med. 2023 (Jun); 16: 3. Triangulation was achieved through: 1) interviewing participants from different disciplines and multiple sites (data source triangulation); 2) involving several researchers in data coding (researcher triangulation); 3) repeating the analysis with the same researcher six months later (data triangulation); and 4) peer debriefing on the entire process of the emerging categories and final themes with independent experts. Data Collection Instruments Scientific articles addressing CM were examined through a narrative review to guide the directed approach. The narrative review included articles on the philosophical aspects of the CM theory found in Google Scholar containing the keywords “common morality” and “medical ethics”. At the time, Google Scholar listed 146 articles on the theory of “common morality” in medical ethics. Thirty-three of those, which extensively discussed the philosophical aspects of the theory, were included in this study. The three themes that emerged from the extracted codes and categories were: 1) the existence of CM; 2) the universality of CM; and 3) CM as an a priori or a posteriori concept. Finally, the findings were transcribed as a questionnaire guide. The principal investigator (LZ) interviewed each participant. The interview guide was designed to explore the participants' opinions and experiences with CM, notably how they understood and applied the CM concept. Based on the responses, exploratory questions were asked to discover any deeper perspectives. For example, interviewees were asked to discuss various ethical topics and how they would resolve hypothetical medical ethics dilemmas, such as a mother's request for a non-medical abortion. Does the interviewee defend the mother's autonomy by following Western bioethics, or does he/she respect the life of the fetus to comply with jurisprudence? Finally, the remaining subjects were searched, if any. The interviews were audio recorded, listened to several times, and then transcribed by the interviewer (the principal researcher). The tone of the interviewee (including surprise, anger and protest) was noted in the transcription if it affected the understanding of the concepts. Units of the Study Thirteen faculty members with an average age of 46 and an average of 14 years of work experience were interviewed. The meaning unit of analysis consisted of any part of the CM-related transcript that could be coded under a category to represent A dialog on common morality in medical ethics in a pluralist setting in Iran J. Med. Ethics. Hist. Med. 2023 (Jun); 16: 3. 6 a single theme. Table 1 shows the demographic data of the participants. Data Processing The principal interviewer (LZ) transcribed all of the data. Participants were anonymized using numbers. The data coding process was verified in two ways: a) the main researcher did the coding twice at an interval of six months, and b) two co- researchers did the coding separately. Comparison of the results showed that these two methods did not produce significantly different results. The initial coding was accomplished manually by the principal researcher. The initial codes (tags) were grouped into categories in order to determine whether a coherent and meaningful pattern existed. This step was performed several times to avoid double selection, overlapping, or missing data and to ensure the re-coding or new coding of previously coded data. Data Analysis To interpret the data obtained from the interviews, the directed and conventional approaches of the content analysis technique were used sequentially. The directed approach analyzed the opinions and conceptualizations of the participants. The interview questionnaire guide was prepared based on the findings of the narrative review, as mentioned earlier. The theme of CM ontology was extracted from 4 categories: the existence of CM, the universality of CM, the relationship between CM and experience, and the relationship between CM and human sensory perception. In order to explore the interviewees' experiences with the concept, new categories were created inductively through the conventional approach, starting directly with the transcribed data to describe them. This coding approach led to the theme of CM epistemology based on the three categories of participants' moral intuition, moral reasoning, and moral decision-making. Techniques to Enhance Trustworthiness In order to ensure trustworthiness, Lincoln & Guba's criteria (1985) were used (18). Trustworthiness was maintained through: 1) the proper purposive snowball data sampling, prolonged interaction with data, appropriate meaning units, good data coverage of categories and themes, the consensus in researchers' codings, and peer debriefing by three faculty members (credibility of findings); 2) repeating the entire analysis process within six months with no significant change in the results (dependability of findings); and 3) interviews with experts in several fields from different academic centers who had diverse views and academic levels (transferability of findings). Zahedi L., et al. 7 J. Med. Ethics. Hist. Med. 2023 (Jun); 16: 3. This study is reported according to the “Standards for Reporting Qualitative Research (SRQR) guideline (19). Results Thirteen faculty members from five disciplines (medicine, medical ethics, moral philosophy, Islamic theology, and sociology) were interviewed. The male-to-female ratio was 1:6. The average age of the participants was 46 years and they had an average of 14 years of work experience. Academic levels included: full professors, associate professors, assistant professors, and doctoral students. Table 1 shows the demographic data of participants. Table 1. Demographic data of participants Variable N (%) Gender Male Famale 8 (61.5) 5 (38.5) Expertise Medical ethics Medicine Philosophy of ethics Islamic theology Social sciences 8 (61.5) 9 (69.2) 3 (23) 2 (15.3) 2 (15.3) Academic Level Full professors Associate professors Assistant professors Doctoral students 1 (7.7) 7 (53.9) 3 (23) 2 (15.3) Work Experience < 10 years 10 - 17 years More than 17 years 2 (15.3) 10 (76.9) 1 (7.7) In this study, a total of 374 initial codes were extracted from the interviews. After collapsing and clustering, two themes of CM ontology and CM epistemology were identified in seven categories. Theme 1: CM Ontology At first, a directed approach was adopted. The authors formulated questions from semi-structured interviews based on the narrative review findings. CM ontology was derived from participants' perspectives on CM in four categories: CM existence, CM universality, the relationship between CM and experience, and the relationship between CM and human sensory perception. The categories, subcategories and initial codes of the CM ontology are shown in Table 2. A dialog on common morality in medical ethics in a pluralist setting in Iran J. Med. Ethics. Hist. Med. 2023 (Jun); 16: 3. 8 Table 2. Categories, subcategories and initial codes of CM ontology Categories Subcategories Initial Codes CM Existence 1.CM as a reality 1. a reality dependent on an inner sense such as intuition 2. a reality dependent on an inner sense such as conscience 3. a reality dependent on an inner sense such as an innate virtuous nature 4. a reality dependent on an inner sense such as a common nature (Fitrah) 5. a reality dependent on an inner sense such as reasoning 6. a reality dependent on an inner sense such as will 7. a reality dependent on external elements such as social moral norms 8. a reality dependent on external elements such as social health determinant s 2.CM as a fantasy 9. a fantasy due to its indetermina cy 10. a fantasy due to the Zahedi L., et al. 9 J. Med. Ethics. Hist. Med. 2023 (Jun); 16: 3. pluralist characteristi cs of the individual’s values 11. a fantasy due to dependence on the agent, the observer and their goals CM Universality 1.CM as a generalizable concept 1. shared by all because it is intuition- oriented 2.CM as an un-generalizable concept 2. not shared by all because of the individual’s intentions and benefits that influence behavior more than morality 3. an un- shared, individual, diverse and divergent concept because people create morality through their thoughts The Relationship between CM and Experience 1.CM as an a priori concept 1. self-evident and requiring no argument 2.CM as an a posteriori concept 2. influenced by cultures and subcultures 3. influenced by individual preferences The Relationship between CM and Human Sensory Perception 1.related to human sensory perception 1. related to rationality 2.outside of human sensory perception 2. related to Fitrah 3. neither related to A dialog on common morality in medical ethics in a pluralist setting in Iran J. Med. Ethics. Hist. Med. 2023 (Jun); 16: 3. 10 rationality nor Fitrah 1-1 CM Existence In the literature, there are debates about whether CM exists as a pillar of human interactions or a variable non-real entity. Participants approached this concept in the subcategories of "CM as a Reality" and "CM as a Fantasy". The first considered CM as a reality dependent on an internal sense (such as intuition, conscience, innate virtue, Fitrah or common nature, reason and will), or dependent on external realities (such as moral norms or determinants of social health). Other faculty members believed that CM was a fantasy because of its indeterminacy, the pluralistic nature of people's values, or its dependence on the moral agent, the observer, and their goals. In this regard, the participants stated: “Human creation is based on the common nature (Fitrah) that God placed in humans. Therefore, CM is rooted in human nature.” [Participant No. 3] “Anything that conforms to the moral norms of the society is compatible with CM.” [Participant No. 7] “CM depends on what the values mean to the person and what image of the values they have formulated in their mind.” [Participant No. 10] 1-2 CM Universality This category questions whether or how the CM concept can be generalized and discusses whether the principles of CM are applicable. Uniformity, stability and completeness are other characteristics that express the generalizability of CM. Two subcategories of "generalizable concept" and "non-generalizable concept" emerged from the participants' input. According to many participants, CM is a self-evident concept shared by all morally committed individuals. Other participants conceived CM to be an ungeneralizable concept because it is influenced by many factors. In this regard, some of the participants’ comments were as follows: “CM is a universal concept because it involves philanthropy or the feeling of empathy that people feel for each other to increase human capacity, alleviate the suffering of others and create a sense of solidarity.” [Participant No. 12] “Commonality is merely an abstraction. In the real world, we have to constantly develop specifications about principles to reach an agreement across cultures." [Participant No. 8] Zahedi L., et al. 11 J. Med. Ethics. Hist. Med. 2023 (Jun); 16: 3. "Common values are equivalent to universal values. However, values are pluralistic because they are subjective.” [Participant No. 9] 1-3 The Relationship between CM and Experience If an entity is related to experience, it is a posteriori concept, a relationship that an a priori concept lacks. Thus, if the participants believed that CM was not influenced by experience, they considered it a pre-theoretical and a priori concept. If, however, they believed CM to be influenced by an individual's lived experiences and culture, they would consider it as posteriori. Most of the participants thought that CM was an a priori concept. In this regard, some of the participants stated: “CM is a pre-cultural, pre-religious, pre-ritual, pre-geographical and pre-historical ethos that is common to all people.” [Participant No. 13] “CM is self-evident and requires no argument; however, the weight of moral principles depends on the culture.” [Participant No. 1] “Moral propositions are not abstract because they have analytical presuppositions and are not independent. Therefore, morality implies a social contract.” [Participant No. 9] 1-4 The Relationship between CM and Human Sensory Perception While rationality and intuition are natural human sensory perceptions, religious beliefs are related to supernatural issues. Compared to the narrative review, this category was uniquely identified from the two subcategories of CM's relationship with metaphysical and natural subjects. Fitrah, which means the purity and innocence that Muslims believe all human beings are born with, represents the relationship between CM and a supernatural entity; rationality, as human sensory perception, establishes this relationship with a natural subject. Some of the participants associated CM with Fitrah, while most connected it to rationality. In this regard, two of the participants stated: “Human dignity is one of the important and comprehensive principles in all religions, especially Islam. It is in accordance with rationality and is close to divine Fitrah.” [Participant No. 12] “CM is closely related to rationality, but religious stereotypes prevent the generalizability of its principles.” [Participant No. 4] Theme 2: CM Epistemology At this point we conducted a conventional content analysis and inductively extracted new categories from the participants’ experiences with the concept. The theme of CM epistemology was derived and developed from the three categories A dialog on common morality in medical ethics in a pluralist setting in Iran J. Med. Ethics. Hist. Med. 2023 (Jun); 16: 3. 12 of moral intuition, moral reasoning and moral decision-making, resulting from the initial codes (Table 3). Table 3. Categories, subcategories and initial codes of CM epistemology Categories Subcategories Initial Codes Moral Intuition Moral foundations: 1. Not inflicting harm 2. Equity 3. Loyalty 4. Authority 5. Purity 1. Deciding according to justice, altruism and honesty 2. Truthfulness, keeping promises, tolerance, recognizing others, giving dignity to man and humanity, sanctity of life, respect for nature, and attention to God affect decisions Moral Reasoning 1. Respect for autonomy 1. Avoiding religious stereotypes and following rationality 2. Respect for religious instructions 2. Not harming anybody because religious instructions prohibit it 3. Respect for life 3. Respecting personal choices to the extent that they do not harm others Moral Decision- Making 1. Pro-choice 1. Acting according to the parents' will because they have the right to choose to have an abortion 2. Pro-life 2. Acting according to religious teachings, which consider abortion acceptable before the fourth month of gestation but forbidden thereafter 2-1 Moral Intuition Thinking may either be a rapid, non-thinking process that is automatic and emotional, or a slow and deliberate one. The former emphasizes the importance of social and cultural influences, and the latter reflects the role of education. In this study, participants' impulsive, quick and unconsidered statements about moral principles expressed during the interviews were perceived as their moral intuitions and the equivalent of their cognitive moral foundations. Based on Haidt's social intuitionist theory of moral foundation (20), statements were classified into five subcategories: not inflicting harm, equity, loyalty, authority and purity. In this regard, one of the participants stated: “I make my decisions based on justice, altruism and honesty” [Participant No. 2]. From this statement, the modules of “fairness” (for justice and honesty) and “loyalty” (for altruism) were extracted. “Truthfulness, keeping promises, tolerance, recognizing others, giving dignity to man and humanity, the sanctity of life, respect for nature and attention to God are among the most influential principles in my decisions.” [Participant No. 13]. Zahedi L., et al. 13 J. Med. Ethics. Hist. Med. 2023 (Jun); 16: 3. From this statement, the modules of “fairness” (for truthfulness), “loyalty” (for keeping promises, tolerance, recognizing others, and giving dignity to human beings and humanity), and “purity” (for the sanctity of life, respect for nature, and attention to God) were extracted. 2-2 Moral Reasoning Moral reasoning establishes a relationship between the participant's moral intuition and moral action. In this research, three subcategories of respect for autonomy, respect for religious instructions, and respect for life were induced from the initial codes. In this regard, some of the participants stated: “In this type of decision, I consider many factors, including the mother's mental background, goals, and social circumstances.” [Participant No. 9] “I do not accept at all the right to abortion based on the autonomy of the mother. This request is against the Islamic philosophy.” [Participant No. 10] “I respect personal choices as long as they don't hurt others.” [Participant No. 5] 2-3 Moral Decision-Making Decision-making is a cognitive process that leads to a choice. Therefore, the participant's reaction to a pregnant woman's request for a non-medical abortion is considered their decision. In this research, two subcategories of pro-life and pro- choice were identified. Below are the statements of two of the participants in this regard: “I follow the wishes of the parents because it is up to them whether to choose abortion or not.” [Participant No. 4] “I make a decision from a jurisprudential point of view: Haq al-Nas says that we are obliged not to violate the rights (of the fetus).” [Participant No. 2] Discussion This qualitative study explored the main aspects of CM from a pluralist academic perspective in order to enhance insights into the concept of CM and its characteristics. In this study, the authors generated the two themes of ontology and epistemology of CM. The first was extracted from the participants' opinions, and the second from their experiences with CM. In an interdisciplinary manner, CM ontology was extracted from the participants’ comments, reflecting their philosophical viewpoints and the way they conceptualized CM. CM epistemology, on the other hand, was identified in their experiences with CM. Experiences are related to social influences and are therefore explored in the field of social psychology. A dialog on common morality in medical ethics in a pluralist setting in Iran J. Med. Ethics. Hist. Med. 2023 (Jun); 16: 3. 14 CM is conceptualized as a set of universal norms shared by all morally committed individuals and is applicable to all people in all places (9). The integration of Rawls' reflective equilibrium theory with the concept of human rights is one of the distinctive features of Beauchamp and Childress' theory (21). However, balancing and specification in reflective equilibrium ignite debates about the existence of CM and the validity of universal moral principles in terms of their independence. A Debate about CM Ontology Ontology is the science of the existence of moral concepts and their general characteristics, a debate that shapes most of the history of philosophy (22 - 25). In this study, most CM proponents saw it as a universal reality, while most critics of CM saw it as a non-universal and non-fundamental illusion without reality. The former believed CM to be a reality dependent on an internal sense, such as intuition and conscience, or external elements, such as social health determinants (relative to their expertise). The latter regarded it as a fantasy because of its indeterminacy and dependence on the moral agent, observer, and their goals. In terms of the universality of CM, for some participants, CM was a universal concept because it is intuition-oriented. Others called it a non- universal, individual and divergent concept because it is created by people’s thoughts, intentions and interests. As realists, Beauchamp and Childress defend the existence and universality of CM (26, 27). The two dimensions of existence and independence constitute the cornerstone of realism. However, non-realists typically reject realism by discarding one of these dimensions (28). Moral relativists believe that the moral system has no unified definition due to the influence of interconnected sets of values, virtues, norms, procedures, identities, institutions, technologies and evolved psychological mechanisms that are formed through individual and cultural tendencies. (29). In contrast, universalists such as Beauchamp and Childress believe that some shared characteristics or qualities are mind-independent. Their universalistic view has been criticized from various aspects. Universal principles do not take into account cultural differences, the diversity of concepts associated with moral principles, and value judgments dependent on culture (30 - 34). Attention is directed toward culturally-defined moral meaning systems. In this way, the generalizability of moral principles is denied due Zahedi L., et al. 15 J. Med. Ethics. Hist. Med. 2023 (Jun); 16: 3. to individual rights and individualistic views (35, 36). The variety of interpretations of principles highlights the role of the moral agent, an important aspect that is overlooked in Beauchamp and Childress’ CM theory (37). Critics of this theory argue that even emotions influence moral judgments. Beauchamp and Childress' CM theory ignores the characteristics of a particular situation, for instance psychological considerations (38). The existence of implicit meta-ethical individual commitments that are not verbally discussed affects moral judgments (39). According to moral relativism, moral judgments and beliefs vary significantly across time and contexts, and their validity depends on the individual or culture. This view undermines universally agreed moral norms or values. Moral relativists believe in the relativity of knowledge because all knowledge is dependent on the knowing mind (40). Here, the presuppositions that lead to different processes of knowledge, namely experiences, become crucial. However, the logic of understanding remains the same (41). Some experts believe that we know moral propositions in advance; they are called apriorists and discuss morality as an entity independent of experience, which is true only through thinking and reasoning (42). Others think morality is a perception that comes from experience and empirical observations. In other words, the issue is whether morality is discovered or created. In this study, the participants discussed the relationship between CM and experience: some believed that CM is self-evident and does not require reasoning, while others thought that culture and individual preferences influence CM. Researchers have recognized the same basic cognitive processes, the existence of limited universal values that are not linked to cultural preferences, and significant similarities in moral phenomena across various cultures (43 - 45). These findings contribute to the acknowledgment of CM as an a priori concept. However, many opponents of CM consider it an a posteriori concept due to individual and cultural factors influencing it. Some say that genetics contributes to cultural learning in moral development (46). Others have focused on the influence of psychological antecedents of behavior and emotional experiences, and the influence of emotions, situational variations and social perceptions in shaping moral judgment (47, 48). Some have evaluated the role of attitudinal goals in behavioral responses and the relationship between moral reasoning or pro-social behaviors A dialog on common morality in medical ethics in a pluralist setting in Iran J. Med. Ethics. Hist. Med. 2023 (Jun); 16: 3. 16 and the underlying mechanism of protecting reputation or avoiding offending others (49, 50). From a cultural perspective, some who see CM as an a posteriori concept believe that moral traits are value-laden cultural entities (51), and others emphasize social factors such as the influence of intergroup attitudes and prior social beliefs that shape moral foundations (52). According to Darwinian theory, the universal and common foundation of CM represents different stages of moral evolution and is related to rationality as a product of evolution by natural selection (53). However, some researchers suggest reconceptualizing beliefs such as "natural" or "intuitive" because they have have been unable to establish a relationship between intuitive or analytical thinking and supernatural beliefs. They believe that factors other than cognitive style help shape and maintain supernatural beliefs (54). In this study, some participants pointed to the relationship between CM and human sensory perception. They linked CM either to rationality as human sensory perception or to Fitrah as a supernatural entity beyond human sensory perception. A Debate about CM Epistemology Epistemology focuses on the nature of knowledge and evidence, the logic of knowledge justification, and types of inferences (55). In short, it deals with how we can learn about the outside world through inference (56), and connects the mind with reality. In this study, the interconnected set of moral intuition, moral reasoning and decision-making was identified and thematized as CM epistemology since justification is a fundamental concept of epistemology. The thinking process can either be a rapid, non- analytical involuntary emotional process, or a slower, more deliberate and analytical one; the former highlights social and cultural influences, and the latter is a reflection of acquired knowledge and education. Haidt believes that moral judgments are primarily driven by automatic emotional responses. They are spontaneous, intuitive, effortless and rapid. His social intuitionist model emphasizes the importance of social and cultural influences. (57). However, there is a slower and more deliberate, rule-based and effortful thinking process. (58). There are debates as to which one is more important or which one takes precedence over the other. Haidt’s model presents five cognitive foundations: not inflicting harm, equity, loyalty, authority and purity, all of which guide moral intuition and emotional response (59). Not inflicting harm and Zahedi L., et al. 17 J. Med. Ethics. Hist. Med. 2023 (Jun); 16: 3. equity are considered individualistic moral foundations because they highlight the rights of autonomous individuals; loyalty, authority and purity constitute binding moral foundations that focus on values related to sociality and spirituality and emphasize a collective focus on group cohesion (60, 61). As shown in Table 4, these five foundations refer to a wide range of actions and virtues. Table 4. Actions and virtues attributed to the modules of the Moral Foundations Theory (62) Modules of Moral Foundation Theory Attributed Actions and Virtues Not Inflicting Harm Disliking pain, virtues of kindness, gentleness, nurturance, caring, empathy, synergy, peace, tranquility, security Equity Not cheating, virtues of fairness, altruism, justice, respecting rights, autonomy, human dignity Loyalty Avoiding betrayal, virtues of loyalty, patriotism, self-sacrifice for the group Authority Avoiding subversion, virtues of leadership and followership, deference to legitimate authority, respect for traditions, respect for religious values, tolerance Purity Avoiding degradation, virtues of disgust over depravity, striving to live, avoiding immoral activities, sacredness of life, being faithful to God Conclusion CM theory is a cornerstone of medical ethics, but in practice, its role in medical decision-making is controversial. This study highlighted the relationship between the philosophical and socio- psychological dimensions of CM. Two themes of CM ontology and CM epistemology were extracted from the interviews. These findings strengthen our insight into CM content in a pluralistic setting. The results showed that the basic concept of CM has multidisciplinary aspects that are pivotal in promoting CM understanding among consultants and decision-makers of medical ethics in pluralistic settings. More studies are needed to investigate the influence of cultural, social, theoretical, ideological and individual factors on the conceptualization of CM in medical ethics in Iran. Funding This study was part of Ladannaz Zahedi’s Ph.D. dissertation in medical ethics entitled “Common Morality and Intercultural Issues” and was financially supported by the School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. Acknowledgements The authors gratefully acknowledge the participants in this study. 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