by Pierre Mallia MD MPhil PhD MRCP FRCGP
Associate Professor of Family Medicine and Patients’ Rights
Department of Family Medicine, Medical School
University of Malta

The PUME matrix helps us define ‘what are we discussing’. In a moral debate we often bring in many arguments, some of which have to do directly, and others indirectly with the main moral issue at hand. Moreover the moral issue may lead to other ethical choices and to areas or issues of which we are unsure. In order to clarify one’s thinking, in teaching and in moral debate, it is useful to distinguish therefore the main moral argument at hand, for example, sale of organs, from the pragmatic moral issues which arise – which indeed can have weight on the outcome. Then there are other ethical choices to be made – are there exceptions when we can tolerate the sale of an organ, for example if it is put as a condition in one’s will – is it ethical? There are areas which we are unsure about – unsure whether they form part of the main moral argument or are more pragmatic such as the use of masturbation as an argument against Invitro Fertilization. PUME stands for Pragmatic, Moral, Unsure and EthicalI.

The four main areas therefore are:

  1. The central MORAL question being discussed.
  2. PRAGMATIC moral issues related to the central moral question.
  3. Areas in which we are UNSURE between the above.
  4. Other ETHICAL outcomes or choices related to this issue.





Figure 1: PUME Matrix

We see that areas 2, 3, and 4 can all have an influence on the central moral question. This means that although we can find nothing inherently wrong with the central issue, the other three areas can have enough weight to make it overall prohibitive, as we shall see. Conversely, the central issue may be inherently wrong, for example the use of animals in experiments, but under certain circumstances, and because of the benefits, we allow it. Clarifying areas 2 – 4 is important as the reasoning may change in time. Thus we tolerate pollution to have cars, but if cars exceed a limit, the pollution may be too much, or indeed we may have created other problems, such as congestion. We then revisit the central argument.

Having a matrix with these for areas, allows for better clarification in thinking, and especially in discussion. The matrix has indeed been used in group discussions both for teaching and public debates and can be used by a facilitator to focus the argument. He may, for instance, say, ‘yes, indeed, that is an important point. It is perhaps a pragmatic moral argument, which although important, is not the main issue we are discussing; it is more of an outcome of the issue, which if resolved, will still leave us having to answer what we are debating here. Let us put it under Pragmatic Moral Issues.’

The PUME matrix is a mnemonic to remember four areas of a moral debate. It is useful insofar as it helps one distinguish between the true moral arguments and those which can be ‘resolved’. This helps one distinguish in turn what are the true areas of conflict, where there is a difference in values, and areas of potential dispute, which if resolved, can help move one forward. One has to keep in mind that we may resolve a hundred disputes without resolving the main conflict, given that the conflict has to do more with a difference in values. To illustrate this by an external example, one can resolve many disputes between the Jewish and Palestinian states, and yet the main conflict between them remains. On the other hand, we may not really have a strong objection to the moral issue per se, but what matter more are the other moral issues which are raised. These I term the ‘pragmatic issues’. This is clearly illustrated by the cases for Invitro Fertilization and that of Organ Transplantation described below.

The reason for putting them in a matrix is two-fold. A matrix makes it easier to picture a problem. One can separate the arguments and put them into the respective box. This can even be done in one’s mind, since it is simple. Conversely, the columns on the left hand side are the main moral arguments, whilst the columns on the right are outcomes and choice with which we still have to deal. On the other hand, if we look at the matrix as rows, the upper row deals with moral issues external to the problem at hand, whilst the lower row is more inherent to the problem. Even if some are not the main issue at hand (the ethical choices), they are a direct result of the moral issue.

On the other hand the most important column for discussion is the left. We have to immediately divide the moral issues into the pragmatic ones and the real one being discussed. In the example of organ transplantation, the real issue is the morality of sale of organs; abuse of sale, or exploitation are pragmatic moral issues, which albeit can have an overall weight and become themselves the moral issues to decide the fate of the moral issue being discussed, are not in and of themselves the central moral issue – sale of organs. Conversely, with IVF, the fact that IVF can result in children with defects is indeed a moral issue, but a pragmatic one. If we resolve it,  we are still faced with the moral issue of whether IVF is a morally good thing. People may then focus on the real discussion.

The matrix may or may not be useful to some, however it does have the advantage of clearly defining what we are talking about and at least agreeing on what is at stake and what is the true moral issue and what is not.


I The PUME matrix was devised over several years of public debate and reflective teaching in bioethics with students of the University of Malta, and not least after the training imparted in Malta in adult learning, by the RCGP. I had been using the argument of separating the main argument at hand, from those other moral issues that arise from the main one, in order to create less confusion and to focus on the argument at hand.