BACKGROUND: Previous research explored students' reasoning in the face of professional dilemmas, using interviews in response to videotaped scenarios. This study determined the effects of a change in context (to a written exam) and format (video versus text scenarios) on students' response patterns. METHOD: Fifty-three students were randomized to videotaped or text-based scenarios in the context of a mock written exam. Responses were coded by two raters. RESULTS: Interrater reliability was high (kappa = 0.872). There were no differences in response patterns between the video and text groups. When compared with the interview setting, students' exam responses showed a shift towards more "acceptable" rationales for action; however, they still considered implications for themselves. CONCLUSIONS: This shift in responses indicates that students took the exam seriously. Their continued reference to implications for themselves might therefore reflect a sense that their status as students makes these considerations legitimate; alternatively, students' interpretation of altruism may be different than what the profession avows.