Moral dilemmas, moral reasoning, and genital herpes.

Sexuality and morality are closely interwoven. For example, in many religions, including traditional Judaism and Christianity, sexual behaviors can determine whether a person is considered moral or immoral (Kelly, 1992). As a result of this association, sexual decisions may often be viewed as moral choices. This bond between sexuality and moral decisions has intensified in recent years, because the choices an individual makes can determine whether that person, or his or her sexual partner, acquires an incurable or even fatal sexually transmitted disease (STD). People who have acquired STDs are often viewed as immoral because of the disease itself or what they did to acquire it (Bruce & Bullins, 1989). These issues highlight the importance of understanding moral thought regarding STDs.

Issues surrounding genital herpes and other STDs provide a rich arena for examining moral reasoning. Each time a person who is infected with an STD begins a new sexual relationship, he or she may be faced with a dilemma of whether to tell the person about the disease and risk rejection, humiliation, loss of confidentiality about the disease, and other adverse effects, or to refrain from discussing the disease with the potential partner and jeopardize the health of the partner (Jadack, Keller, & Hyde, 1990). An individual who is not infected with a disease may face issues of whether to bring up the topic of STDs and risk hurting the partner's feelings, stay silent about his or her concerns, or remain celibate to avoid contracting a disease. Understanding how people reason in these situations is crucial because there is evidence that many people who have STDs are opting to avoid telling their sexual partners about the disease (Perry, Ryan, Fogel, Fishman, & Jacobsberg, 1990; VanderPlate & Aral, 1987). In the interest of health promotion, these issues are, therefore, of vital importance. Issues surrounding genital herpes provide a particularly good arena for understanding moral decision making surrounding sexuality. Because it is an episodic, incurable, and sexually transmissible condition, persons who have genital herpes are frequently faced with powerful moral dilemmas that relate to sexuality. Therefore, our goals for the study were to examine moral reasoning of persons with genital herpes, which may help define the nature of moral reasoning as it relates to conflicts associated with herpes and other STDs, and to test the theoretical perspectives that define the moral domain as they pertain to conflicts about the experience of STDs.

Conceptual Frameworks

Two theoretical perspectives have been examined extensively and have spurred discussion and debate regarding moral development and reasoning: Kohlberg's cognitive-developmental theory of moral reasoning (Kohlberg, 1969, 1984) and Gilligan's perspectives on moral development (Gilligan, 1982; Gilligan & Attanucci, 1988).

Moral stage theory. Kohlberg (1969, 1984) proposed three levels and six stages of moral development. The pre-conventional level consists of Stage 1, in which the individual is motivated primarily by the avoidance of punishments, and Stage 2, which involves more of an emphasis on maximizing rewards to the self. The conventional level of moral reasoning is comprised of Stage 3, in which the individual is motivated by the anticipation of actual or imagined disapproval of others, and Stage 4, in which moral reasoning is based upon the avoidance of dishonor or guilt. Finally, in the post-conventional level, the individual is motivated by a desire to maintain self-respect and the respect of others (Stage 5) or by universal ethical principles (Stage 6).

Kohlberg believed that an individual's moral reasoning is based upon a number of factors, including age and educational level, and that individuals advance through stages invariably and in a fixed order. Colby, Kohlberg, Gibbs, and Lieberman (1983) provided support for Kohlberg's theory in their longitudinal study of 58 men.

Kohlberg also assumed that people reason consistently across situations. Thus, if an individual progresses to a certain stage, it is predicted that he or she will use the structure of reasoning associated with that stage to solve all conflicts. Therefore, Kohlberg did not believe that people will reason differently depending upon their situational context (Kohlberg, 1984).

However, Kohlberg's theory has been widely criticized. A major criticism has been the level of abstraction of the moral dilemmas that Kohlberg used in his research on these issues. Many dilemmas to which Kohlberg's participants responded were quite far removed from the experience of most people; therefore, Kohlberg's findings have been criticized for being unrealistic and artificial (Gilligan & Attanucci, 1988; Walker, 1984). However, Walker, deVries, and Trevethan (1987) found that participants' moral reasoning stage scores were consistent across real-life (i.e., those that participants generated from their experiences) and hypothetical dilemmas (i.e., those provided by researchers). This suggests that Kohlberg's stage model of moral reasoning may be more applicable across a variety of abstract and real-life dilemmas than critics might expect.

Kohlberg's research has also been criticized for its predominant use of male participants. Kohlberg used data collected from men to propose a theory that he believed could be applied to both men and women. Many feminists argue that the experiences of men are not necessarily relevant to women's experiences and, therefore, applying Kohlberg's moral reasoning stage theory to women causes the moral reasoning of women to appear inferior (Gilligan, 1982). However, Walker (1984), using meta-analysis to review existing studies, found no gender differences in Kohlbergian moral reasoning.

Moral orientation theory. Carol Gilligan (1977, 1982) was among those who criticized Kohlberg's theory for being biased in favor of men. According to Gilligan, women have a moral reasoning style that is qualitatively different from, but not inferior to that of men. She referred to the moral reasoning styles of men and women as moral orientations. Gilligan (1982) suggested that men are taught to be individualistic and autonomous, whereas women are socialized to be dependent and relationship oriented. Therefore, Gilligan asserted that women's moral standards are based upon the consequences of their decisions for other people. In contrast, as a result of their socialization, men look to abstract societal standards of morality for guidance in their moral decision making. Gilligan labeled the "masculine" form of moral decision making a "justice" orientation and the "feminine" form a "care" orientation. She proposed that the two orientations should be viewed as different but equally valid approaches to moral reasoning.

There has been some empirical support for Gilligan's proposal that women and girls are more likely to use a care orientation and men and boys are more likely to use a justice orientation (Donenberg & Hoffman, 1988; Ford & Lowery, 1986; Stiller & Forrest, 1990). However, other researchers have found no such gender differences (Cohn, 1991; Friedman, Robinson, & Friedman, 1987; Thoma, 1986). For example, Walker et al. (1987) found that both women and men use justice and care orientations without a clear preference for one over the other. Men and women did make statements that were qualitatively different; however, the moral orientations of the statements were not significantly different. These theoretical frameworks proposed by Gilligan and Kohlberg were used in the current research to examine moral reasoning about STD and traditional dilemmas among people who have or do not have genital herpes.

Genital Herpes

More than 30 million Americans are estimated to have genital herpes (Strong & DeVault, 1994). Transmission of genital herpes occurs primarily through genital contact with an infected partner. Therefore, it is critical that individuals who have genital herpes abstain from all types of genital contact when they are having a herpes outbreak. There is also a chance that the virus can be spread through a process known as asymptomatic viral shedding (AVS), which involves transmission of the disease even when the infected individual is not experiencing an outbreak (Mertz, 1993).

Genital Herpes and Moral Decision Making

Individuals who live with genital herpes are expected to have a unique perspective on conflicts pertaining to STDs. Certainly, individuals who have the disease have spent more time thinking about the implications of contracting herpes. These individuals may be more aware of the seriousness of the disease and therefore more concerned about protecting their sexual partners. They may also be more sensitive to the possibility that they will contract another STD (Catania, Coates, & Kegeles, This may be a justifiable concern, because having genital herpes has been correlated with an increased risk of acquiring HIV (Holmberg et al., 1988; Hook et al., 1992; Stamm et al., 1988).

Jadack, Hyde, Moore, and Keller (1995) were among the first to study moral reasoning about dilemmas that involve STDs. Moral reasoning of groups of older and younger college S students were compared to determine if these age groups differed in their moral reasoning about these types of dilemmas. Dilemmas that probed such topics as confidentiality, notification of past partners, and the use of condoms were included. Jadack et al. (1995) found that, consistent with Kohlberg's theory, younger participants scored at a lower level of moral reasoning than participants in the older group. However, inconsistent with Kohlberg's predictions, an individual's level of moral reasoning was dependent upon the content of the dilemma to which he or she was responding, suggesting that moral reasoning level is no necessarily consistent across different types of dilemmas. Furthermore, inconsistent with Gilligan's moral orientation theory, most participants did not consistently respond according to one orientation. Participants overall were more likely to use a care orientation for dilemmas that revolved around serious interpersonal relationships and a justice orientation for dilemmas involving more casual sexual relationships, indicating that the situational context is a major force eliciting care or justice reasoning. Also inconsistent with moral orientation theory, no significant gender differences were found.

One drawback of this study was that it lacked a comparison between the STD dilemmas and the standard dilemmas used in Kohlberg's (1969) research. We attempted to remedy this omission in the current study.

The Current Study

The current research used both Gilligan's and Kohlberg's theoretical perspectives to examine the nature of moral reasoning about dilemmas that involve STDs and to compare the reasoning of persons with genital herpes and persons without an STD on both STD-related and traditional Kohlberg dilemmas.

The purpose of this research was to examine how individuals who have genital herpes and those who have not experienced an STD think about hypothetical situations that involve the possibility of spreading an STD and theoretically to compare responses on STD dilemmas with responses on standard Kohlberg dilemmas. Using Kohlberg's framework, we predicted that no differences would emerge in levels of moral reasoning between people with herpes and people with no experience with STDs, people would score at the same levels of moral reasoning on Kohlberg dilemmas than on STD dilemmas, younger adults would score at lower levels of moral reasoning than older adults, and more educated people would score at higher stages than less educated people. Using Gilligan's framework, we predicted that no differences would emerge on moral orientation between responses on Kohlberg dilemmas and responses on STD dilemmas, women would use a care orientation to a greater extent than men, and people who demonstrate a care orientation would score lower on moral stage than those who demonstrate a justice orientation. Gilligan might also predict that persons with an STD might have a different experience than those who have not had an STD, which might lead them to view the STD dilemmas differently than people who have never had an STD (Taylor, Gilligan, Sullivan, 1995). However, Gilligan was silent about whether people should use a justice versus care orientation, depending upon their disease experience. An additional purpose of the study was to determine how disease characteristics (such as severity of symptoms) of people who have herpes would be related to the moral stage and moral orientation of the participants.

The research employed STD dilemmas that include currently important and relevant issues. The dilemmas are hypothetical, yet were developed and written to be realistic, relevant, and meaningful to the people in the study.

From a theoretical point of view, this study can provide important tests and her criticisms of Kohlberg's theory. It is also possible to compare responses to Kohlberg's traditional measure of moral reasoning and measures that use other timely dilemmas.

Method

Participants

Fifty-nine people (26 men and 33 women) participated in the study. Thirty (12 men and 18 women) participants reported that they had been diagnosed with genital herpes, and 29 (14 men and 15 women) reported having never experienced an STD. Fifty percent of the participants were single, 22.7% were married, 18.2% were divorced, and 9.1% were cohabitating but not married. Ninety percent of the participants were White. The mean age was 31.8 (35.2 for those with herpes, 29.0 for those with no STDs) for men. The mean age was 30.8 (30.8 for those with herpes, 30.9 for those with no STDs) for women. Men were not significantly older than women, t(57) = .42, ns. Participants were asked if they were currently in a sexual relationship: 33% of the herpes sample and 45% of the non-herpes sample reported that they were.

The herpes and non-herpes groups did not differ in age, 01, 57) = 1.08, ns; educational level, 01, 57) = 1.63, ns; or income [chi square] (5) = 1.35, ns. There were also no significant differences between the herpes and non-herpes groups in whether they were currently sexually active, [chi square] (5) = .82, ns.

Participants in the herpes groups had been aware they had herpes for an average of 7.9 years, SD = 6.33. They had an average of 3.52 recurrences per year, SD = 3.00. The average amount of impact of herpes on the participants' lives was 2.96, SD = 1.26. This item was rated on a five-point scale where 1 = very little impact and 5 = great impact. The average amount of pain associated with herpes outbreaks was 2.32, SD = 1.27. This item was rated on a five-point scale where 1 = not at all painful and 5 = extremely painful.

Recruitment

The participants who had herpes were recruited via advertisements in community and campus newspapers and fliers posted throughout the community. The text of the advertisements was "Herpes Study--Persons with genital herpes needed for a research study examining the social and psychological issues surrounding this disease. Confidential. Payment will be offered."

Before they agreed to participate, all respondents were told that they would first fill out a brief questionnaire and that they would then be presented with a series of hypothetical scenarios. They were also told that they would be tape recorded as they responded to the situations and that some situations they would be presented with would be related to sexual issues. Finally, they were told that the interview was structured so that they could describe their experiences if they wished, but that this was not a requirement of the study. Potential participants in the herpes group were told that the interview would take approximately 45 minutes and they would be paid $10 for their participation. Potential comparison group participants were told that the interview would take approximately 30 minutes and that they would be paid $5 for their participation. (The participants in the non-herpes groups were told that their participation would take approximately 30 minutes, as opposed to 45 minutes, because they did not complete the questionnaire about experiences with genital herpes, which is described in the next section.) No potential participants refused after hearing the description of the study. However, two participants in the herpes group initially agreed to participate but failed to show for their appointments and declined to reschedule. One participant who had another chronic, episodic STD other than genital herpes (genital warts) was excluded from the analyses (although he was interviewed and paid). No other participants in the herpes group reported having any other STDs. Additionally, one participant in the comparison group was initially scheduled, failed to show for his appointment, and was not rescheduled. Twelve participants in the control group were selected from a pool of community members who had volunteered to participate in psychological experiments. The remaining 18 participants in the comparison group were recruited from an introductory psychology class at a local junior college.

Measures

Background information questionnaire. This questionnaire consisted of questions about the participants' age, gender, ethnic origin, educational level, and religious background. Additionally, several questions assessed the participants' sexual history, including sexual orientation and current sexual relationships. The participants with herpes received a more extensive questionnaire that contained questions related to their experience with genital herpes, including how long they had the disease, and the frequency and severity of their outbreaks. All questions in the questionnaire were previously used with a sample of individuals who have genital herpes (Jadack et al., 1990).

Genital herpes knowledge questionnaire. This 24-item questionnaire consisted of true or false questions that assess the respondents' knowledge of genital herpes (Jadack et al., 1995). Questions about the characteristics of the virus and the disease and the ways in which the disease may be spread were included in the questionnaire. One item addressed the individual's knowledge about AVS. This instrument was scored by computing the total number of correct responses. The face validity of this instrument was determined by a panel of experts: three nurse clinicians working with persons who have STDs, a nurse researcher expert in genital herpes, and a psychologist expert in human sexuality. This instrument has been used in previous research examining the genital herpes disease experience (Jadack et al., 1990).

Other diseases. All participants were provided with a list of STDs and asked to indicate which diseases they had previously experienced. Participants in the non-STD group who reported experiencing an STD would have been excluded from further analyses. However, this situation did not arise.

Dilemmas. Two dilemmas depicted protagonists in situations that involve STDs (Jadack et al., 1995). In one dilemma, the protagonist, Mary, has had genital herpes for three years and currently has no symptoms. She is trying to decide whether she should inform Jack, a potential sexual partner, of the disease or take the chance of spreading the disease to him through AVS. In the second dilemma, John is trying to decide whether to have sex with a new partner, Sally, without a condom or to risk an adverse reaction from her if he suggests that they use a condom. In this dilemma, neither character is known to be infected, but the possibility that either might be infected is raised. These dilemmas were developed through extensive pilot work completed prior to this study in which young adults and adolescents were asked to write dilemmas about STDs (Jadack, 1992).

The other two dilemmas were chosen from the Colby et al. (1987) manual. One dilemma addresses the moral issues surrounding euthanasia. A doctor is trying to decide whether to give a lethal dose of a painkiller to a patient who is in extreme pain and is asking to die. The other dilemma involves a tailor who is trying to determine if he should report a man to the authorities whom he recognizes to be an escaped prisoner, even though the former prisoner is now making valuable contributions, to society. The four dilemmas were presented in random order. The interviews were tape recorded

For each of the dilemmas, the participants were asked a series of questions specific to the dilemma. For example, in the dilemma about Mary, a representative question is "Should Mary tell Jack that she has herpes?" In the John dilemma, a representative question is "Should John break the mood and get a condom?" In the euthanasia dilemma, one of the questions is "Should the doctor give the woman the drug that would make her die?" Finally, in the dilemma about the escaped prisoner, one of the questions is "Should the tailor report Victor to the police?" Each series of questions asked the participant to determine what the protagonist should do in the situation and whether the proposed course of action is the right thing to do.

Procedure

Upon arrival, participants signed a detailed informed consent form indicating that they agreed to participate and be tape recorded. Participants were interviewed by a female undergraduate (the first author). Participants were interviewed individually in a private room designated for this purpose. Before beginning the interview, participants were first presented with the background information questionnaire and the genital herpes knowledge questionnaire. Participants who had herpes were given a longer questionnaire that included questions about their experiences related to contracting and living with genital herpes.

Each participant was then given the four dilemmas described previously, presented in random order. Interviewers asked a series of predetermined questions about each dilemma. All responses to the dilemmas were tape recorded.

Data Analysis

Coding. The interviews were transcribed verbatim. The transcriptions were analyzed according to two methods: Kohlberg's moral stage model and Gilligan's moral orientation model.

To determine the moral stage score, interviews were placed into Kohlberg's stages by the methods outlined by Walker et al. (1987). First, each moral reasoning statement was matched with a criterion judgment outlined in the Colby et al. (1987) manual. Because the coding scheme was intended for use with Kohlberg dilemmas only, the STD dilemmas were identified according to general stage structure and definitions and critical indicators for each consideration, irrespective of dilemma or Kohlbergian moral issue. The coding of the Kohlberg dilemmas followed the manual more closely. Combined, these scores were used to generate a score for the percentage of statements that fell into each moral stage outlined by Kohlberg. From these scores, a weighted average score (WAS) was first computed. This score is based on information about use at all Kohlberg stages and is given by the sum of the products of the percent usage at each stage multiplied by the stage number (range = 100-500). Therefore, a score of 200, for example, indicates that a person is reasoning predominantly at Stage 2, whereas a score of 400 indicates that the person is reasoning predominantly at Stage 4. Next, a Global Stage Score (GSS) was determined. The GSS represents all stages of reasoning that respondents use for more than 25% of the statements they make when they are responding to dilemmas. It includes both pure stages (i.e., 1, 2, 3, 4, 5) and intermediate stages between two pure stages (i.e., 1/2, 2/3, 3/4, 4/5). The coders for this method were certified and trained in workshops expressly for learning Kohlberg coding. Once again, two coders scored these dilemmas, with the first coder scoring all dilemmas and the second scoring 15 randomly chosen transcripts to establish reliability. The Pearson r for agreement between coders with respect to STD WASs was .78. The Pearson r for agreement between coders with respect to Kohlberg WASs was .84. Overall, with respect to, GSSs, there was 97% agreement between raters within 1/2 stage. Discrepancies were resolved by a third coder.

A few illustrative quotations of the three most common moral stages found in the current study and justice-based and care-based moral reasoning are provided next. These serve as examples of the types of reasoning that are characteristic of a given stage of moral reasoning. However, these are not necessarily the most common responses.

Moral reasoning representative of Kohlberg's Stages 2, 3, and 4 were most commonly found in this study. An example of Stage 2 reasoning is "[John should stop and get a condom] because it's too dangerous nowadays . . . with AIDS. That's the biggest thing there. STDs, most of them are curable and stuff, but you have herpes and you have AIDs, which is deadly, He [should use a condom] for his own safety."An example of Stage 3 reasoning is "Mary should tell Jack because if it were me, my conscience wouldn't let me live with that . . . I would just feel awful." An example of Stage 4 moral reasoning is "[Mary should tell Jack] because in our society we want to cut down on disease of any kind, because AIDS and herpes and everything is going to become rampant in our society and if, if we can just cut it by one more person . . . maybe we could help each other. . . ."

Interviews were coded for Gilligan's moral orientation using the methods described by Lyons (1982). This coding system outlines five categories of statements that may be considered illustrative of the use of a care orientation and five that indicate the use of a justice orientation. If an idea mentioned in the interview fell into any of these categories, it was labeled a "care" or a "justice" consideration. Content analysis for each dilemma results in three scores: frequency of care considerations, frequency of justice considerations, and predominant orientation. To determine these measures, the total number of "care" and "Justice" ideas was tabulated for each dilemma. The category for which there was a greater number of ideas for a given dilemma was considered the predominant orientation of that dilemma. Thus, if an individual had more care statements than justice statements, the individual was assigned a care orientation. If participants made more justice statements than care statements, they were assigned a justice orientation. Individuals who made an equal number of justice and care statements were assigned a mixed orientation. One coder scored each of these dilemmas, and the second scored 15 randomly chosen interviews to establish interrater reliability. Cohen's Kappa (Cohen, 1961; McLaughlin & Marascuilo, 1990) was used for each determination of interrater reliability. Cohen's Kappa for independent coders identifying codable segments, or considerations, of,the transcripts was .75. Once considerations were categorized, Cohen's Kappa was determined again, this time for the percentage of agreement between coders in the categorization of considerations into "justice" and "care" statements. Interrater reliability at this step was .79. All discrepancies were resolved by discussion between the two coders.

Illustrative examples of some types of care-based and justice-based reasoning will now be provided. Once again, these quotations are exemplars of the types of statements thought to reflect care-based or justice-based reasoning. However, these are not intended to reflect the most common types of reasoning. Two care-based reasoning statements are "[John should stop and get a condom] because she would understand if they were really interested in each other and they were ready for sex ... then they should obviously be emotionally involved enough that she would understand if he wanted to be safe and he would understand if she wanted to be safe" and "Wary should tell Jack that she has herpes] because if she really cares for him then she won't want to risk infecting him." Two examples of justice-based reasoning are "Wary should tell Jack that she has herpes] because he has a right to know that he needs to use condoms and just needs to be aware of it. I would, if I were in the reverse shoes, I would want to know that my partner had herpes. Period. I would just want to know" and "[John should stop and get a condom before having sex with Sally because] I just think he has an obligation when he's, you know ... doing an act such as this that he as well as Sally--I think they both have an obligation to each other to make sure they're protected and, you know, they are acting responsibly."

Results

Moral Stage

Two WASs were computed for each respondent. Overall, the mean WAS for Kohlberg dilemmas was 318.1 (SD = 47.4). The overall mean WAS for STD dilemmas was 312.0 (SD = 39.3). These WAS scores indicate that the mean moral reasoning stage was approximately between Stage 3 and Stage 4. WAS scores ranged from 220 to 420 for Kohlberg dilemmas and 217 to 375 for STD dilemmas, which indicates a range from approximately Stage 2 to approximately Stage 4. Means and standard deviations for individual WASs are shown in Table 1. To test for gender differences and disease group differences, two 2 (gender) x 2 (disease group: STD, no STD) analyses of variance (ANOVAs) were computed for each dilemma type, using WAS as the dependent variable. A Mauchly sphericity test supported assumptions of homogeneity of variance. All interactions were nonsignificant.

Table 1
Mean Weighted Average Scores (SD) for Dilemma Types

                         Weighted Average Scores
Groups               Kohlberg Dilemmas    STD Dilemmas
Gender:
  Males                 314.9 (45.3)      316.7 (44.9)
  (n = 26)
  Females               320.6 (49.6)      308.4 (34.6)
  (n = 33)
Disease Group:(*)
  STD                   328.5 (46.2)      325.3 (38.1)
  (n = 30)
  No STD                307.4 (47.0)      298.3 (36.3)
  (n = 29)

(*) Significant disease group difference for STD dilemmas, p < .05

To determine if moral reasoning responses differed across different types of dilemmas based on gender and disease experience, a 2 (gender) x 2 (disease group) x 2 (dilemma type) ANOVA was conducted with WAS as the dependent variable. There were no main effects of dilemma type, gender, or disease group (all ps [is greater than] .05). The null results for gender and disease group replicate other analyses in this study. There was a significant three-way interaction among dilemma, group, and gender, F(1,55) = 5.35, p [is less than] .03. Post-hoc analyses revealed that women in the herpes group scored significantly higher on the Kohlberg dilemmas (M = 334.8) than women in the no STD group (M = 303.6). Furthermore, men in the herpes group scored significantly higher on the STD dilemmas (M = 341.0) than men in the no STD group (M 295.9).

For Kohlberg dilemmas, there was no main effect for gender, F(1,57) = .21, ns. The WAS scores for women (M = 320.6) were not significantly higher than the WAS score for men (M = 314.9). Likewise, the ANOVA revealed no main effect for disease group, F(1,57) = 2.93, ns. The herpes group had WAS scores (M = 328.5) similar to the WAS scores of the no STD group (M = 307.4).

For STD dilemmas, there was no main effect for gender, F(1,57) = .65, ns. Men did not reason at a higher level (M = 316.7) than women (M = 308.4). However, the ANOVA did reveal a main effect for disease group, F(1,57) = 7.99, p [is less than] .008. Thus, people in the herpes group reasoned at a significantly higher level (M = 325.3) than people without an STD (M = 298.3).

Knowledge about genital herpes. The herpes group was significantly better informed about genital herpes than the non-herpes group, F(1,57) = 14.30, p [is less than] .0005. However, knowledge about genital herpes was not significantly correlated with WAS scores or the Kohlberg dilemmas, r = .22, ns, or the STD dilemmas, r = .23, ns. One specific type of knowledge that may have an impact on an individual's moral reasoning about STDs is an understanding of AVS. Based on their responses to one question on the genital herpes knowledge questionnaire, more participants who had herpes were aware of the possibility of AVS than those who did not have herpes, [chi square] (2) = 6.71, p [is less than] .04. However, participants who were aware of AVS did not differ in their WAS scores from those who were unaware of AVS, t(1,25) = .60, ns, for WAS scores for Kohlberg dilemmas, t(1,25) = .95, ns, for WAS scores for STD dilemmas.

Age and education level. Consistent with Kohlberg's hypotheses, level of education was associated with WAS scores for the Kohlberg dilemmas, r = .39, p [is less than] .03. However, level of education was not associated with WAS scores for the STD dilemmas, r = .22, ns. Inconsistent with Kohlberg's hypotheses, there were no significant correlations between age and WAS scores (ps [is greater than] .05).

Disease characteristics and moral stage. Participants who had herpes for longer periods of time did not have significantly higher WAS scores than those who had more recently acquired the disease, t(29) = .67, ns. A significant relationship between pain and WAS scores on the STD dilemmas emerged, such that participants with more pain during recurrences had lower WAS scores, r = -.46, p [is less than] .02. Those who had more recurrences also had lower WAS scores on the STD dilemmas, r = -.46, p [is less than] .02. However, there was no association between ratings of "impact of herpes on daily life" and WAS scores on the STD dilemmas, r = .02, ns. Furthermore, there was no association between length of time the individual reported having the disease and WAS scores on the STD dilemmas, r = .01, ns. None of the symptom severity items were significantly related to WAS scores on the Kohlberg dilemmas (all ps [is greater than] .05).

Moral Orientation

Moral orientation data were analyzed in two ways: overall moral orientation scores computed across all dilemmas and moral orientation scores computed separately for Kohlberg and STD dilemmas. Moral orientation data are shown in Table 2.

Table 2

Frequencies (%) of Moral Orientation by Dilemma Type

                        Kohlberg Dilemmas    STD Dilemmas
Disease Group(*):
  Herpes:
  Care                      8 (26.7%)         21 (70.0%)
  Justice                  20 (66.7%)          9 (30.0%)
  Mixed                     0 (0.0%)           0 (0.0%)
  (Missing data)            2 (6.7%)
No STD:
  Care                      5 (17.2%)          3 (10.3%)
  Justice                  20 (69.0%)         21 (72.4%)
  Mixed                     3 (10.3%)          5 (17.2%)
  (Missing data)            1 (3.5%)

(*) Significant disease group difference for STD dilemmas, p < .001

Disease group differences. With respect to STD dilemmas, people with genital herpes used a care orientation to a greater extent than those without genital herpes, [chi square] (2) = 18.80, p [is less than] .05. These people discussed issues of obligations and rights to maintain relationships to a greater extent than did persons without genital herpes. People without an STD spoke more often of the principle of using condoms to prevent disease, irrespective of the relationship. With respect to Kohlberg dilemmas, there was no significant difference in the moral orientation between disease groups, [chi square] 2(2) = 3.68, ns.

Gender. Researchers and theorists have suggested that the care orientation is the predominant orientation of women and the justice orientation is the predominant orientation of men (Gilligan, 1982; Lyons, 1988). In this sample, there were no gender differences with respect to moral orientation. For STD dilemmas, 13 (42.3%) women and 11 (39.4%) men used a care orientation, [chi square] (3) = 4.40, ns. Similarly, 20 (76.9%) women and 20 (66.7%) men used a justice orientation when considering Kohlberg dilemmas, [chi square] (2) = 1.46, ns.

Stability of moral orientation. To compare moral orientations across dilemma types, two analyses were conducted. First, a McNemar Change test was conducted with type of dilemma (Kohlberg or STD) as one variable and moral orientation (justice or care) as another. Those participants who had a mixed orientation were excluded from this analysis because such a small number fell into this group and because a mixed orientation has no theoretical significance. This test indicated that significantly more participants used a care orientation for the STD dilemmas than for the Kohlberg dilemmas (2-tailed p [is less than] .02). Similarly, a Cochran Q test was conducted, again using moral orientation and dilemma type as the variables. A similar pattern emerged, Q = 7.20, p [is less than] .008. Overall, respondents gave an average of 13.8 (SD = 4.04) care-related responses and an average of 10.69 (SD = 3.89) justice-related responses. Frequencies of moral orientation for persons in each disease group are shown in Table 2. For the Kohlberg dilemmas, persons used the justice orientation (67.8%) to a greater extent than the care orientation (22.0%). The preference for justice-related reasoning was much smaller when responding to STD dilemmas. Here persons used the justice orientation (50.8%) only 10% more than the care orientation (40.7%). Thus, the results of these analyses converge to suggest that the participants in this sample use a justice orientation more for Kohlberg dilemmas and a care orientation more for STD dilemmas.

Disease characteristics and moral orientation. People who predominantly used a justice orientation did not differ in their disease characteristics (i.e., amount of pain experienced during recurrences', number of recurrences, and overall "impact of herpes on daily life") from those who predominantly used a care orientation (all ps [is greater than] .05). However, those who had herpes for longer periods of time were more likely to use a care orientation than were those who had herpes for a shorter amount of time.

The Relationship Between Moral Orientation and Moral Stage

According to Gilligan (1982), people who use a care orientation are at a disadvantage when using Kohlberg's scoring system because they score lower on Kohlberg's measure than those with a justice orientation. Chi-square analyses were conducted for each dilemma type. Because there were so few participants with a mixed orientation, analyses were conducted only for those people with either a justice or care orientation. For STD dilemmas, there was no significant relationship between global stage score and moral orientation, [chi square] (3) = 4.14, ns. Similarly, for Kohlberg dilemmas, there was no significant relationship between global stage score and moral orientation, [chi square] (3) = 1.51, ns.

Discussion

Moral Stage and STDs

In general, people who reported a history of recurrent genital herpes showed a higher level of moral reasoning in response to dilemmas about STDs than those who did not have an STD. Typically, people with herpes reasoned at a Stage 3 or 3/4 level, whereas persons without genital herpes reasoned at a Stage 2/3 or Stage 3 level. This finding indicates that, for people with genital herpes, reasons for telling or not telling a partner about an STD were generally focused on the rights of the partner and obligations and rights necessary to maintain good relationships. It appears that people who have had the experience of contracting herpes are more focused on their obligations and responsibilities to other people (a higher level of moral reasoning) than are their non-infected counterparts. The Stage 2/3 or 3 levels of reasoning or persons wit out genital herpes indicate that their reasoning was focused on their risk or probability of acquiring a disease. This finding is consistent with that of Jadack et al. (1995), who found that college students who had not experienced an STD reasoned at about a 2/3 level for dilemmas related to STDs. That people without herpes reason about STDs at a Stage 2/3 or Stage 3 level lends support to current teaching methods. If uninfected people are primarily considering risk to self, then the current educational message that promotes safer sexual behavior through use of condoms to protect oneself against STDs is very appropriate.

In addition to the STD dilemmas, respondents were given dilemmas from the Colby et al. (1987) manual, allowing comparisons between reasoning on standard Kohlberg dilemmas and reasoning on STD dilemmas. Few significant differences emerged. Notably, persons were consistent in their moral reasoning, except for those who did not have herpes in response to STD dilemmas, lending partial support to Kohlberg's assumption of reasoning consistency.

Neither know edge about herpes in general nor specific knowledge about AVS was related to moral reasoning stage. Given the emphasis that public health officials have placed on education about diseases, one might expect that education would allow the participants in this study to reason at a higher level. The lack of association between knowledge about herpes and stage of moral reasoning suggests that it may be important to stress factors other than education in our attempts to encourage safer sex behaviors.

Moral Orientation

Not surprisingly, persons used justice-related reasoning to a greater extent with Kohlberg dilemmas. This is to be expected, given that Kohlberg's dilemmas were developed with the assumption that justice is primary in defining the moral domain (Kohlberg, 1984. When given dilemmas about sexual situations that are relevant to respondents' day-today lives, people do not prefer one orientation or another, using both justice- and care-related reasoning in response to the dilemmas. Therefore, similar to findings by Walker (1984), there is little reason to suspect that justice and care orientations are mutually exclusive. Rather, people used varying combinations of both orientations in response to STD conflicts.

Furthermore, we found that women in the herpes group scored higher on the Kohlberg dilemmas than women in the no STD group, and that men with herpes scored higher on the STD dilemmas than men in the no STD group. These results were unexpected and difficult to interpret. Therefore, we feel that the findings should be replicated in future studies before we attempt to understand them.

Contrary to Gilligan's (1982) predictions, men and women did not differ in their moral orientations. In general, men and women used reasoning reflecting both orientations. The lack of gender differences is inconsistent not only with Gilligan's moral reasoning model, but also with previous research finding gender differences in approaches to sexual situations, such as the proposal to use condoms (e.g., Campbell, Peplau, & DeBro, 1992; Helweg-Larsen & Collins, 1994; Sacco, Levine, Reed, & Thompson, 1991). Society has specific scripts for men and women in sexual situations. As a result, in sexual situations, gender roles are likely to be particularly salient. Therefore, there are likely to be distinct differences in the causal dynamics of condom use for men and women (cf. Helweg-Larsen & Collins, 1994). Given these reasons for expecting gender differences, the lack of gender differences in this sample is particularly remarkable. We might conjecture that men and women in sexual situations are more likely to differ in behaviors but less likely to differ in cognitions about the sexual situation.

Moral orientation was not related to moral stage. Individuals who used a care orientation for a particular dilemma did not score lower on moral stage than did those who use a predominant justice orientation. These findings do not support the idea that Kohlberg's theory puts people who use a care orientation at a disadvantage when using the Kohlbergian scoring system. Furthermore, these findings do not support the idea that women use a care orientation to a greater extent than do men. Similar to participants in a study by Walker (1991), participants in this sample reasoned about STD conflicts using both care and justice orientations.

Lyons (1982, 1988), Gilligan (1982), and Noddings (1984) all stated that moral orientations represent distinct ways in which persons think about problems. It has often been assumed that if moral orientation provides a framework for understanding morality, then there should be consistency in reasoning across dilemmas, and persons should have a clear preference one orientation over the other. However, it is clear in this study that people did not prefer one orientation over another and in fact used a mix of orientations when responding to dilemmas about STDs. Therefore, our findings suggest that researchers and theorists should not use a particular orientation as a marker for moral stage. Nor should a moral orientation be considered a stable characteristic of a certain gender or individual (Brown, Debold, Tappan, & Gilligan, 1991). These data suggest that, regardless of gender, people can and do think about moral problems from a variety of points of view, depending on the situation or context being considered.

Disease Experience and Moral Reasoning

One final set of exploratory findings concerns the relationship between certain disease characteristics and moral reasoning. Our findings suggest that those who have had more negative experiences with herpes may also have lower moral reasoning scores on the dilemmas related to STDs. Therefore, we might speculate that people who have more negative symptoms become self-focused about the disease and therefore base their moral reasoning on maximizing rewards to the self. In contrast, people who have relatively few symptoms may be less self-focused and therefore able to be concerned about others with respect to the disease. Of course, this interpretation is ex post facto, and the pattern of results was not replicated for all of our disease experience measures. Still, this finding contradicts Kohlberg's theory directly, because it suggests that an individual's situational context may be related to his or her moral reasoning.

Limitations

Several limitations of this study restrict our ability to draw conclusions. First, we cannot make the assumption that the differential moral reasoning levels of the herpes and no STD groups are due purely to their disease status. The participants in the herpes group were recruited on the basis of their disease status and were given additional questions about their experience with genital herpes before they completed the in interview. Therefore, this group may have been primed to think about genital herpes, and this priming may have had an impact on their thinking about topics related to STDs. Other researchers should make attempts to prime STD issues equally in STD and no STD groups.

Second, this is a rather homogenous sample, especially in terms of ethnic background. A more comprehensive study would allow for ethnic comparisons and the different meanings of sexuality in different cultures. This should certainly have an impact on the way people in these communities think about issues related to STDs. A related point is that this is a small sample. Final judgment about the veracity of these findings should be withheld until the findings are replicated with a larger and more diverse sample of participants.

A third and final limitation concerns the coding scheme that was used to code for moral orientation. In this system, anyone who provides one more care response than justice responses is classified as having a care orientation. Conversely, anyone who gives one more justice response than care responses is classified as having a justice orientation. However, it is reasonable to assume that a person who gives, for example, 12 justice responses and 1 care response might be different from a person who gives, for example, 5 justice responses and 4 care responses. Coding systems that are more sensitive and that more explicitly address issues of how much people use one orientation over the other would be instrumental in understanding differences between justice and care orientations.

Theoretical Implications

In one sense, this research may address the limitations of the current moral reasoning theories for understanding issues in the specific domain of STDs. The current models assume a constancy of moral reasoning across situations and make no allowance for individual differences based on experience with the specific moral situation. The current findings of context-related differences in moral judgments are unusual in light of these theories. Our findings therefore suggest a need to develop new theories of moral reasoning that account for domain-specific experience and knowledge, as well as qualitative differences in moral reasoning, depending upon the type of moral problem that an individual encounters.

However, in another sense, these findings display the remarkable flexibility of current moral reasoning theories. They can be used to categorize a wide variety of moral thought across different situations and different people. Gilligan (1982) suggested that there are two types of moral thought, neither of which should be considered "better" or "more developed." The flexibility of Kohlberg's moral reasoning model could be improved by abandoning the hierarchical stage assumption and instead viewing each stage as a different type of moral reasoning, which is not necessarily any better than any other stage. Both theories could be improved by incorporating the idea that people may reason at different stages and different orientations, depending on their situational context.

Sexuality and morality are closely interwoven. Our results suggest that an understanding of sexual issues can deepen our understanding of morality, and conversely, understanding moral issues and conflicts can enhance our understanding of sexuality.

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Manuscript accepted September 23, 1996

This research was supported by a University Wisconsin-Madison Trewartha Undergraduate Research Grant awarded to the first author. The authors thank Barry E. Collins for his helpful comments on a previous version of this manuscript.

Correspondence regarding this article may be addressed to Terri D. Conley, Department of Psychology, University of California, Los Angeles, 405 Hilgard Avenue, Los Angeles, CA 90095. E-mail: [e-mail].