A 37-year-old pregnant women in her 7th week of gestation presents with NVP. This was not her first pregnancy; she has three healthy children. Her previous pregnancies were a nightmare as a result of NVP. She is reluctant to take prescription medications for her NVP and prefers some "natural" remedy. Her friends told her that ginger (Zingiber officinale Roscoe) might help subside her symptoms. Recently, she caught flu and now she coughs and has nasal congestion. Her medical history shows that she has type II diabetes mellitus and a mild hypertension. She is on antihypertensive medications, oral hypoglycemic agents, insulin, a statin, and a low dose aspirin. Although she tried to breastfeed her three children, in every time her milk was not enough to totally depend on and feeding was supplemented with formula. The woman is overweight and often suffers joints pain. Her previous attempts to lose weight were futile as she could not control her appetite. Although she was not screened for ulcer, she often suffers heartburns and dyspepsia, especially with certain foods. She works as an accountant and often complained having difficulty falling asleep. She always wanted to seek a medical advice for this problem but did not have the opportunity to see a physician for this problem.
Although this case might lead to multiple professional and ethical questions, the question suggested was "should this woman use ginger?" This question was posed in neutral and concrete manner and it does not contain any professional or ethical arguments.
The potential alternative decisions in this case are identified without any final decisions made. These potential alternative decisions could be as follows: (1) this woman is recommended to use ginger without any further discussions, (2) this woman is recommended to use ginger after verifying that she is well-informed and understands the risks of using ginger in her case, (3) making a shared decision between this woman and the healthcare provider to use ginger when considering the risks are negligible, or (4) making a shared decision to avoid using ginger in her case. 
Obviously, there were differences in priorities for each alternative decision that need to be considered and which were not immediately clear to make a decision at this stage.
Professional as well as ethical decisions should be substantiated with relevant information. Therefore, all relevant information regarding the potential benefits and risks of using ginger in this case should be understood thoroughly before making any decision. In a previous study, a Delphi technique was followed among gynecologists, other physicians who frequently see pregnant women with NVP, and pregnant women to achieve consensus on the potential benefits and risks of using ginger for NVP that should be addressed in a clinical consultation. The potential benefits and harms were obtained from interviews with gynecologists, physicians, and women as well as from the literature.
It was important to take into consideration that the efficacy and safety of ginger in managing NVP are still indecisive considering a number of conflicting reports. Previous studies showed that ginger decreased aggregation of platelets, increased acid production in the stomach, and had the potential to interact with many medications. A previous study demonstrated that ginger contains gingerols that have the ability to inhibit arachidonic acid-induced human platelet serotonin release and aggregation in a potency comparable to that of aspirin. The compound 8-paradol, which is one of the constituents of ginger, has a relatively potent inhibitory action on the cyclooxygenase (COX-1) and has antiplatelet aggregation activity. Bleeding, especially in the first trimester could be severely detrimental to pregnant women and their fetuses and in many cases was shown to lead to miscarriage. Although ginger is often labeled as "generally regarded as safe" in the US, in Germany and Finland, some health regulatory agencies have advised against using ginger in pregnancy.
Some studies alluded to a link between ginger and increased risk of spontaneous abortion and fetal developmental abnormalities. These suggestions are contradictory to what Portnoi et al. showed in Canada, that the use of ginger in the first trimester did not increase the risk of spontaneous and therapeutic abortions in 187 women exposed to ginger compared to 187 women who were not exposed to ginger, and those shown in a larger study conducted in Norway; however, in conservative views, these results should be considered with caution and patients as well as healthcare providers might take into consideration an inconclusive link between using ginger and risk on the fetus and continuity of the pregnancy. Ginger was also shown to reduce blood pressure and blood sugar levels. However, the effects of ginger on blood sugar are expected at higher doses than those recommended for NVP and might take months to appear. A previous study showed that ginger extracts blocked voltage-dependent calcium channels and lowered blood pressure in animal models. These findings in laboratory animals were contradictory to those shown in a randomized clinical trial in which ginger, among other herbal preparations, did not bring about significant changes to blood pressure of patients with type II diabetes mellitus. Therefore, it is not clear if the use of ginger might potentiate the effects of insulin and antihypertensive medications and might necessitate adjustment of the doses.
Ginger was also shown to be associated with cardiac arrhythmias, sweating, thirst, dehydration, duodenal ulcer, diarrhea, mild headache, fever, mild skin itching, belching, and heartburns. On the other hand, ginger might help alleviate cough, flu, joints pain, and dyspepsia. Ginger might also induce somnolence, help reduce hypercholesterolemia, increase milk production, improve skin, help controlling appetite, and promote weight loss.
The stakeholders in this case were the woman herself and her caring healthcare provider. This healthcare provider could be a physician, pharmacist, herbalist, or another healthcare providers. For this study, a panel of 10 participants was composed. The panelists were 2 physicians, 3 pharmacists, 3 herbalists, and 2 pregnant women. The panelists were provided with the case as well as the potential benefits, side effects, and risks of using ginger in this case. Perspectives of the panelists on the potential benefits, side effects, and risks when appraising benefits and avoiding side effects and risks were obtained.
To investigate how strong these arguments are in this case, the AHP was used. In AHP, panelists use pairwise comparisons to weigh alternatives and facilitate decision making. In this study, the goal was to determine relative weights of benefits to appraise therapeutic effects and avoid side effects and risks on the continuity of pregnancy and the integrity of the developing fetus. The panelists were provided with summaries containing information on safety and efficacy of ginger in NVP. Data relevant to the safety and efficacy of ginger were summarized from Natural Medicines Comprehensive Database, Cochrane Database of Systematic Reviews, and summary of relevant systematic reviews and research papers. The panelists were provided with full text copies of the papers whenever they requested them. The panelists were requested to make pairwise comparisons on a scale of 9-points. The higher the numerical value given to an item (benefit, side effect, or risk), the higher the relative weight of the item compared to the other item being compared with. The panelists were requested to consider the probability of each benefit, side effect, or risk relevant to the case presented while making the pairwise comparisons. The comparisons were conducted in 4 stages. In the first stage, the panelists were requested to rate the weights of the potential benefits. In this stage, 12 potential benefits were compared in pairwise. These benefits were alleviating NVP, alleviating cough, alleviating flu, increasing milk production, decreasing appetite, decreasing cholesterol levels, reducing blood pressure, reducing blood sugar levels, alleviating dyspepsia, improving sleep, improving skin health, and reducing joint pain. In the second stage, the panelists were requested to rate 15 potential side effects in pairwise. These side effects were risk of bleeding, cardiac arrhythmia, irritable bowel syndrome, duodenal ulcer, heartburns, hypotension, hypoglycemia, skin itching, dehydration, belching, thirst, sweating, fever, headache, and diarrhea. In the third stage, the panelists rated 3 potential risks on the continuity of the pregnancy and the integrity of the developing fetus in pairwise. These risks were risk of spontaneous abortion, risk of impairment of fetal development, and risk of fetal hypoglycemia. In the last stage, potential benefits, side effects, and risks were compared in pairwise comparisons. Individual ratings from each panelist were used to compute the comparison matrices in Excel spreadsheets. Relative weight scores as well as their consistency ratios were calculated using the mathematical formulas originally developed by Saaty.
Treatment prioritization analysis was performed on the grounds of analyzing benefits of ginger for this case, potential side effects, and risks to the fetus and pregnancy. Analyzing ratings on the benefits of ginger in this case showed that alleviating symptoms of NVP had the highest weight scores (30.7%  +- 16.6%) and the one-way ANOVA with Bonferroni post hoc multiple comparisons showed that this weight score was significantly higher than other weight scores (p-value < 0.001). Therefore, alleviating symptoms of NVP was ranked 1st. Multiple comparisons showed statistically significant difference in weight scores of alleviating symptoms of dyspepsia compared to all other benefits (p-value < 0.001) except for alleviate cough (p-value = 1.000) and flu (p-value = 0.890). Scores for alleviating symptoms of cough and flu were not significantly different (p-value > 0.05), while they were statistically different from reducing joint pain (p-value < 0.05) and improving skin health (p-value < 0.01). Detailed weight scores of the potential benefits are shown in Figure 1. Multiple comparisons are presented in Supplementary Table S1.
Analyzing ratings of the side effects showed that the risk of bleeding was given significantly higher weight score (p-value < 0.001) than others (24.7%  +- 13.5%) and was ranked 1st. Scores of cardiac arrhythmia and dehydration were not statistically significant (p-value > 0.05). Scores of heartburns (14.8%  +- 6.6%) were significantly higher than all other potential side effects (p-value < 0.01) except duodenal ulcer (p-value = 0.145) and irritable bowel syndrome (p-value = 1.000). Detailed weight scores of the potential unwanted side effects are shown in Figure 2. Multiple comparisons are presented in Supplementary Table S1.
Weight scores for risk of spontaneous abortion (45.8%  +- 3.8%) and risk of impairment of fetal development (41.6%  +- 3.6%) were significantly higher (p-value < 0.001) than those of fetal hypoglycemia. Detailed weight scores of the potential risks to the fetus and pregnancy are shown in Figure 3. Multiple comparisons are presented in Supplementary Table S1.
When benefits were compared against the side effects and risks to the fetus and pregnancy, the former had significantly higher (p-value < 0.001) weight score (72.3%  +- 5.2%). Details of the weight scores are shown in Figure 4. Multiple comparisons are presented in Supplementary Table S1.
From the above results, clearly, we can see that ginger can be recommended for this woman as its potential benefits outweighed its potential side effects and risks to the fetus and pregnancy. In this case, the healthcare provider and the patient herself should take a shared decision to use ginger in her case. The woman should also be informed of the potential side effects and risks of using ginger. In this case, the use of Utrecht method and the AHP provided a framework for ethical as well as professional deliberation to decision making. The use of such methods promotes openness and transparency in decision making based on the perspectives of different stakeholders. Using these methods might help find common grounds between deliberators. It is important to take into consideration that no method of ethical and professional reflection can guarantee the best outcomes. Rather, the quality of outcomes depends on the quality of the ethical as well as professional deliberations themselves and the AHP depends on the perspectives of the stakeholders taken into consideration. Future studies are needed to evaluate the utility of this combined method to facilitate deliberations and decision making in CAM use. Using such methods might help promote transparency in making decisions in patient-centered care in daily CAM practice.