inter-ethics: towards an interactive and interdependent bioethics

INTER-ETHICS: TOWARDS AN INTERACTIVE ANDINTERDEPENDENT BIOETHICSbioe_1810 242..255

TINEKE A. ABMA, VIVIANNE E. BAUR, BERT MOLEWIJK AND GUY A.M. WIDDERSHOVEN

Keywordsdialogical ethics,empirical ethics,participatory research,responsibility practices,elderly care,practice improvement,practical wisdom

ABSTRACTSince its origin bioethics has been a specialized, academic discipline,focussing on moral issues, using a vast set of globalized principles andrational techniques to evaluate and guide healthcare practices. With theemergence of a plural society, the loss of faith in experts and authoritiesand the decline of overarching grand narratives and shared moralities, anew approach to bioethics is needed. This approach implies a shift from anexternal critique of practices towards embedded ethics and interactivepractice improvement, and from a legal defence of rights towards fosteringinterdependent practices of responsibility. This article describes these tran-sitions within bioethics in relation to the broader societal and culturaldynamics within Western societies, and traces the implications for themethodologies and changing roles of the bioethicist. The bioethicist weforesee is not just a clever expert but also a relationally sensitive personwho engages stakeholders in reciprocal dialogues about their practice ofresponsibility and helps to integrate various sorts of knowledge (embodied,experiential, visual, and cognitive-scientific). In order to illustrate this newapproach, we present a case study. It concerns a project focusing on aninnovation in elderly care, based on the participation of various stakehold-ers, especially older people themselves.

INTRODUCTION

Bioethics, like most professions and disciplines, is aproduct of its time. Its rise in the 1960s can be directlylinked to upcoming notions about human beings asautonomous individuals and a critique of medical prac-tice and medical-technical innovations. Decisions madeby medical doctors and experts were no longer automati-cally accepted and trusted, and patients started to ques-tion the authority of doctors. The general public becamemore critical about technological developments, and gov-ernments began to question whether everything that canbe done should be done, given the high costs and prob-lems of equity and justice. Ethicists started to specialize inthe medical field and tried to formulate answers to thesequestions.1 Slowly they formed a countervailing critical

mass against the doctor’s monopoly of the determinationof the good within medicine. Since then the field ofmedical ethics has developed within both universities andmedical practice.

Initially medical ethics focussed on medical doctors,providing them with codes of conduct. Gradually itchanged into healthcare ethics, a discipline which wasbroader in scope, oriented to the whole healthcare field,including nursing and other healthcare practices. Morerecently we see the rise of applied ethics within thedomain of clinical ethics2 and the development of various

1 T.L. Beauchamp & J.F. Childress. 1994. Principles of BiomedicalEthics (4th ed.) New York/Oxford: Oxford University Press; J.D.

Rothman. 2001. The Origins and Consequences of Patient Autonomy:A 25-Year Retrospective. Health Care Anal 2001; 9: 255–264.2 M.D. Bayles. Moral Theory and Application. Soc Theory and Pract1984; 10: 97–120; J.P. Demarco & R.M. Fox, eds. 1986. New Directionsin Ethics – the Challenge of Applied Ethics. New York: Routledge &Kegan Paul; H. Brody. 1989. Applied Ethics – Don’t Change the

Address for correspondence: Tineke A. Abma, Dept Medical Humanities, VU University Medical Centre, Postbox 7057, 1007 MB Amsterdam, TheNetherlands. Email: [email protected]

Bioethics ISSN 0269-9702 (print); 1467-8519 (online) doi:10.1111/j.1467-8519.2010.01810.xVolume 24 Number 5 2010 pp 242–255

© 2010 Blackwell Publishing Ltd., 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA.

types of empirical ethics.3 In these two emergingapproaches the traditional distinction between ethicspractised within the academy and the day-to-day dilem-mas within healthcare practices began to fade away. Theappreciation of the context and complexity of healthcarepractice, and ‘smaller’ ethical issues (e.g. issues related toresponsibilities in daily care) as opposed to the traditional‘big’ and medical moral themes (e.g. end-of-life decisions)grew. Besides this orientation towards practice, respectfor the moral competence of practitioners also increased.For both practical and theoretical reasons, the distinc-tions between ethics and social sciences as two separateepistemological domains started to dwindle. The sameapplies to the distinctions between de-contextual ethicsexpertise and context-specific lay knowledge. We see aprocess of proto-professionalization, which is exemplifiedby medical doctors presenting themselves as ethicists, andethicists starting to use and perform social scientificmethods. The methodology of bioethicists changes fromthe application of theory to practice towards a contex-tual, ethnographic understanding of practices.4

These developments can be understood, according tous, as signs of a more radical movement. We distinguishtwo emerging transitions: from an external critique ofpractices towards embedded ethics and interactive prac-tice improvement, and from a legal defence of rightstowards fostering interdependent practices of responsibil-ity. These transitions will have radical implications forthe future of bioethics, both in philosophical presupposi-tions and in methodology. They challenge us to rethinkour notion of medical practice and the meaning of knowl-edge, inquiry and learning within bioethics. In this articlewe will present these transitions and their implicationsstarting with an analysis of the notions involved, followedby a case study to illustrate various features of this newapproach.

TWO TRANSITIONS

In this section we describe two transitions we envisage forthe future of bioethics. These transitions are linked andshare a focus on the process (versus the provision ofstandards), acknowledgement of practical rationality(versus theoretical rationality) and emphasis on relation-ships (versus atomism).

From an external critique of practicestowards embedded ethics and interactivepractice improvement

From its beginning bioethics focused on the developmentof moral theory and moral principles for the field ofmedicine, but also claimed to be practical and useful forpractices (as compared with the academic field of ethics atthat time). Generally shared principles were supposed tobe helpful for evaluating and guiding medical decisionsand medical practices in general; uncertainty about allkinds of difficult situations could be reduced by suchexternal standards. The stance of bioethics was consid-ered to be both normative and prescriptive; not onlyshould bioethics develop concepts and moral principlesfor medical practice and medical decisions, medical prac-titioners should also adhere to these concepts and prin-ciples. According to the general point of view at that time,bioethics should take an objective view of medical prac-tice. Bioethics claimed to be able to develop an externalcritique of its object. The assumption was that throughrational and logical reasoning, it could determine moralepistemology and, with this anchor point, define what ismorally wrong. External critique however, should alsohave practical impact. It should ideally lead to adjust-ments of practice; medical professionals should changetheir behaviour and rationalize their decisions in thefuture. Medical doctors and other healthcare profession-als had to learn from the knowledge (e.g. reasoning, con-cepts, principles, theories) provided by bioethicists asexperts; it should help them to solve problems through anestablished, well-developed analytical methodology. So,both the knowledge and methodology provided by thebioethicist were regarded as normative tools to repair andbetter to manage complex ethical problems.

In this traditional model, practitioners may provideinformation to the ethicists, and get normative solutionsin return, but they themselves do not have ‘a say’ in thedeveloping normative argumentations and conclusions.They are the object of bioethics experts. Criticismtowards this approach stresses that it often falls short intaking into account the local context and process.5

Subject. In Clinical Ethics: Theory and Practice. B. Hoffmaster, B.Freedman & G. Fraser, eds. Clifton, New Jersey: Humana Press: 183–200.3 A.C. Molewijk et al. Empirical Data and Moral Theory. A Plea forIntegrated Empirical Ethics. Med Health Care Philos 2004; 7: 55–69;G.A.M. Widdershoven, T.A. Abma & B. Molewijk. Empirical Ethics asDialogical Practice. Bioethics 2009; 23; 4; 236–248; H.M. Lindemann,M. Verkerk & M.U. Walker. 2009. Naturalized Bioethics. TowardResponsible Knowing and Practice. Cambridge: Cambridge UniversityPress; Birnbacher, D. Ethics and Social Science: Which Kind ofCo-operation?. Ethical Theory Moral Pract 1999; 2: 319–336;B. Hoffmaster. 1989. Philosophical Ethics and Practical Ethics –Never the Twain Shall Meet. In Clinical Ethics: Theory and Practice. B.Hoffmaster, B. Freedman & G. Fraser, eds. Clifton, New Jersey:Humana Press: 201–230.4 M.U. Walker. 1998. Moral Understandings: A Feminist Study inEthics. New York/London: Routledge.

5 G. Weisz ed. 1990. Social Science Perspectives on Medical Ethics.Dordrecht: Kluwer.

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Theoretically, as discussed in the literature on empiricalethics, the epistemological framework of moral principles(e.g. their authoritative status and their universalisticde-contextualized claims) is considered to be one-sided.6

Methodologically, the question remains of when a certainprinciple is valid and how it should be applied in concretecomplex situations. More fundamentally, it is debatedwhether bioethics should start with principles at all, whenworking in practice. Moreover, criticism from a morepractical point of view (e.g. from education, psychologyand organization literature) stresses the fact that chang-ing or improving practice with principles and rationalreasoning is not really successful.7 Learning is not just amatter of textbook and frontal learning (reading jour-nals, following courses etc). Practitioners start to learnwhen confronted with anomalies in their practice, whentheir routines and habitual ways of thinking are chal-lenged. They learn through reflection in and on action.Learning in and from practice is integrated in action andnot just cognitive but, first of all, experiential andcontext-bound.8 It is learning while doing. Furthermore,

practitioner learning is a social and communal, not just alogical rational process. Finally, if practical reasoning aspart of everyday medical practice is neglected or evendistrusted, then this will certainly affect the practitioners’sense of identity. It may lead to a loss of trust in one’spersonal moral responsibility, and a distrust of thequality of practice specific ways of practical reasoning.

More recently these criticisms and problems have givenway to forms of ethics that are contextual and open topractical experience and to learning from experiencethrough dialogue with others. The idea of practiceinforming these approaches refers to becoming a memberof a community with a shared set of values and norms. Apractice is guided by a shared understanding of andengagement with good action (practical rationality).Members of a practice share an engagement (being adoctor, being a healthcare professional and participant inmedical practice): they are dealing with the same others(patients, clients, but in the case of doctors also nurses,family members, managers etc), have developed a set ofshared understandings and values, are connected toeveryday experience, and have developed a particularlanguage.9 ‘Shared’ refers to a way of doing things that iscommon in a certain field and therefore recognizable as apractice. For example, medical doctors use scientificevidence-based knowledge and clinical experience inorder to define what good action is in medical practice.They have developed stories to solve problems withpatients and stories inform them about actions that needto be taken in case of problems. The doctors’ storiesacknowledge that medical practice is far more complexthan handbooks and evidence-based guidelines assume;doctors also have to deal with the social complexity oftheir practice (impatient patients and family members,managers who want to cut costs, nurses who work inshifts etc).

Actions of practitioners are based on an engaged,embodied and enacted judgement that links knowledge,experience and virtue. Hence, actions and meanings ofactions are complex phenomena which do not fit easilyinto concepts. Judgment, according to Aristotle, starts bytaking into account the concrete details of a particular

6 B. Hoffmaster. Can Ethnography Save the Life of Medical Ethics?Soc Sci Med 1992; 35: 1421–1431; J. Vorstenbosch. 1992. Four Ways ofLeaving the Ivory Tower. Perspectives on Research in Applied Ethics.In The Turn to Applied Ethics: Practical Consequences for Research,Education, and the Role of Ethicist in Public Debate. R. Heeger & T. vanWilligenburg, eds. Kampen: Kok Pharos Publishing House; D.M.Rosenthal & F. Shehadi, eds. 1988. Applied Ethics and Ethical Theory.Salt Lake City, Utah, USA: University of Utah Press; B.J. Crigger.Bioethnography: Fieldwork in the Lands of Medical Ethics. MedAnthropol Q 1995; 9: 3, 400–417; B. Jennings. 1993. Ethics and Ethnog-raphy in Neonatal Intensive Care. In Social Science Perspective onMedical Ethics. G. Weisz, ed. Philadelphia: University of PennsylvaniaPress: 261–272; Birnbacher, op.cit. note 3; A.C. Molewijk. 2006. RiskyBusiness. Individualized Evidence Based Decision-Support and theIdeal ofPatient Autonomy. An Integrated EmpiricalEethicsSstudy (thesis).Leiden: Leiden University Medical Center; B. Molewijk & L. Frith, eds.Special Issue on Empirical Ethics. Bioethics 2009; 23: 4; 193–261.7 K.J. Gergen. 1992. Organization Theory in the Postmodern Era. InRethinking organization. New directions in organization theory andanalysis. M. Reed & M. Hughes, eds. London: Sage; K. Kwakman, K.2001. Leren van Professionals tijdens de Beroepsuitoefening [Learningof Professionals within Practice]. In Human Resource Development.J.W.M. Kessels & R.F. Poell, red. Alphen aan de Rijn: Samson: 229–243; J.P. Kotter & D.S. Cohen. 2002. The Heart of Change. Real-lifestories of how People Change their Organizations. Harvard BusinessSchool Press Boston, Massachusetts. USA; J. Boonstra & L. de Caluwe,eds. 2007. Intervening and Changing, Looking for Meaning in Interac-tions. Chichester, UK: John Wiley & Sons.8 N.M. Dixon. 1994. The Organizational Learning Cycle: How WeLearn Collectively, London: McCraw-Hill; J.E. Wenger. 1999. Commu-nities of Practice: Learning, Meaning and Identity. Cambridge: Cam-bridge University Press; T.A. Abma. Evaluation and Communities asPractice. Psychiatry as a Case Example. Evaluation 2006; 13: 1: 32–48;A. Le May. 2008. Communities of Practice in Health and Social Care.Wiley-Blackwell; C. Mattingly & M. Fleming. 1994. Clinical Reasoning:Forms of Inquiry in a Therapeutic Practice. Philadelphia: F.A. DavisPress; G.W. Roth, D. Lawless. & K. Tobin. Time to Teach: Towards aPraxeology of Teaching. Can J Educ 2000; 25: 1–15; C.K. Montgomery.2006. How Doctors Think. Clinical Judgement and the Practice of Medi-

cine. Oxford: Oxford University Press; C. Kuiper. 2007 The EventMaker. The Hybrid Art of Performing Professionals, Work Setting Reha-bilitation. Den Haag: Lemma; T. Niessen. 2007. Emerging Epistemolo-gies. Making Sense of Teaching Practice. Maastricht: Datawyse; C.L.Bosk. 1979. Forgive and Remember. Managing Medical Care. Chicago:The University of Chicago Press; C.E. Schneider. 1998. The Practice ofAutonomy. Patients, Doctors, and Medical Decisions. New York:Oxford University Press.9 S. Chaiklin & J. Lave, eds. 1996. Understanding Practice: Perspectiveson Activity and Context. Cambridge: Cambridge University Press; J.Forester. 1999. The Deliberative Practitioner. Cambridge, MA: MITPress; T.S. Schwandt. On Modelling Our Understanding of the PracticeFields. Pedag, Cult Soc. 2005; 13 (3): 313–332. See also: Mattingly &Fleming, Roth et al., Kuiper, ops. cit. note 8.

244 Tineke A. Abma, Vivianne E. Baur, Bert Molewijk and Guy A.M. Widdershoven


case. At the same time, it requires reflection upon generalprinciples and standards. The dialectic between thedetailed circumstances of the actual case and the generalprinciples fosters a morally right action.10 Thus, what isright on a certain occasion also depends on the interac-tion, communication and dialogue with others; it cannotbe determined without taking into account the specificcharacteristics of practice. For example, informing thepatient about treatment possibilities and asking what hewants to choose might sound like a form of respectingautonomy. However, the same behaviour can also beinterpreted as leaving the patient alone in her choice andimposing an unreasonable amount of responsibility onher. The meaning of action and words is inherently inter-woven with the details of the situation. A practice in thisconceptualization is therefore ‘intimately concerned withthe timely, the local, the particular and the contingent(e.g. what should I do now, in this situation, given thesecircumstances, facing this particular person, at thistime).11

The knowledge of practitioners is experiential, practi-cal and embodied. It is concrete as opposed to beingabstract and generalized. It is embodied in the sense thatit reflects all of what we are; our personal emotions,standpoints, training and experiences. In conversationswith others practitioners always bring this backgroundinto play; it is impossible to interpret and understandsituations leaving out who we are. This is not wrong; it isinevitable and productive. Prejudices and emotions helpus to focus our observations (to see the salient features)and to delineate what values are important to us. Yet,these prejudices can and should be understood and chal-lenged in dialogue.12 In a true dialogue (as opposed tomechanically following rules and principles) a doctormay learn that the patient who is unwilling to use atherapy is not principally against medication, but hasfears about its negative side effects. This may lead to anadjustment of the therapy; the doctor may search foranother dose or another type of medication, and followits clinical effects as well as the patient’s experience. Thiscan be considered a good dialogue between patient anddoctor. Both parties are open and a new solution is foundthat takes both considerations into account. Hence, notthrough reasoning and arguing about principles, butthrough being sensitive for meaning and dialogue, afusion of horizons emerges.13 Yet the solution found in

one case may not be applicable to another patient or tothe same patient in other circumstances. A practitioneralways has to find out what to do in a specific situation.Complete mastery or control is therefore neither possible,nor desirable.14

Viewing practice as a shared engagement of a commu-nity means that a practice is always inevitably normative.Ethics and practice are entwined. First of all, sensitivityto what is needed in a particular situation requires anengagement and attentiveness to appreciate and under-stand the other and the particulars of the situation.15 Wisejudgment is different from calculation (defining goals andmeans); it also includes a process of valuing. Practicalreasoning and judgment – in line with Aristotle’s notionof phronesis – requires that one is a good person, andconversely, the habit of phronesis will promote virtue inthe practitioner. Values of clinical practice include atten-tion to the patient, reliance on one’s own perceptions,awareness of one’s skills and their limits, careful obser-vation, thoroughness and accurate representation ofwhat has been seen and done. The face-to-face encounter,and the appeal of the patient to the doctor, is central tothe ethos of medicine and nursing. These shared valuecommitments are hardly explicated in the process ofsocialization; they are tacitly transmitted to novices. Themoral is thus implicit in clinical and healthcare practice.16

In this view of bioethics, medical practice and bioethicsno longer stand in opposition to each other. Bioethicsbegins with practice, and with the practical knowledgealready in place. Medical practitioners have a specificunderstanding of what they see as morally right in certaincircumstances; their moral intuitions are grounded in acommunity with a specific history, have developed overtime and are enriched by their work. Bioethicists can helpto articulate these moral persuasions, to foster criticaland self-reflective discussions about actions and values.Bioethicists can become Socratic partners in an interac-tive process to improve a practice. Their theoreticalknowledge is not irrelevant, but it does not take thelead in processes of practice improvement; it first follows

10 M.C. Nussbaum. 1986. The Fragility of Goodness. Cambridge: Cam-bridge University Press.11 T.A. Schwandt. A Postscript on Thinking about Dialogue. Evalua-tion 2001; 7(2): 229; 264–276.12 H-G. Gadamer. 1960. Wahrheit und Methode. Tubingen: J.C.B.Mohr.13 J.M. Anderson. Empowering Patients: Issues and Strategies. Soc SciMed 1996; 43 (5): 697–705; C. Charles, A. Gafni & T. Whelan. SharedDecision-Making in the Medical Encounter: What Does It Mean? (Or It

takes at Least Two to Tango). Soc Sci Med 1997; 44 (5): 681–692: C.A.Barry et al. Giving Voice to the Lifeworld. Soc Sci Med 2001; 53 (4):487–505; P. Bissell, C.R. May, & P.R Noyce. From Compliance toConcordance: Barriers to Accomplishing a Re-Framed Model ofHealthcare Interactions. Soc Sci Med 2004; 58 (4), 851–862; G.A.M.Widdershoven & T.A. Abma. 2007. Hermeneutic Ethics between Prac-tice and Theory. In Principles of Health Care Ethics. R.E. Ashcroftet al., eds. Chichester, UK: Wiley: 215–222.14 Montgomery; Mattingly & Fleming; Kuiper; Forester; Niessen op.cit. note 8; T.A. Abma & M. Noordegraaf. Managers amidst Ambigu-ity. Towards a Typology of Evaluative Practices in Management Set-tings. Evaluation 2003; 9(3): 285–306.15 M.C. Nussbaum, op. cit. note 10; J. Tronto. 1993. Moral Boundaries.New York: Routledge.16 K. Montgomery; C. Kuiper; Mattingly & Fleming, op. cit. note 8.



practice, and then interacts with it.17 The idea is not todevelop theoretical knowledge in advance, so that prac-titioners can apply it, but to assist practitioners in theirprocess of moral deliberation, developing moral andexperiential knowledge, and to help them to cultivatetheir practical wisdom and judgment. In order to be rel-evant in this process, ethical theories have to be flexibleand open. They have to be able both to integrate contex-tual elements and to stimulate practical learning pro-cesses. Hence, the linear model of knowledge productionis replaced by an interactive model of an ongoing knowl-edge development in which bioethicists work along withpractitioners to improve practices, integrating theory andpractice. In this process the bioethicist takes on a new roleof facilitator, fostering a reflective learning process in andwith practice.

We foresee the need for a bioethics, characterized asinter-ethics, that is embedded and develops in interactionwith practitioners. This implies that it is not possible toclaim or conclude that something is morally right orwrong from an outside position. For both epistemologi-cal and practical reasons, a dialogical ethics is needed inorder to understand what is morally right and wrong inthe concrete situation. This is not a relativistic point ofview; it does not diminish the critical power of a norma-tive bioethics. Wrong practices do exist, and can beplaced on a continuum from best, good to less good andwrong practices. Yet such normative conclusions or criti-cism of a specific situation can only be reached in andwith a specific context. As a matter of fact, criticism is afundamental presupposition and start of dialogicalethics. A dialogue is an ongoing process in which differ-ent viewpoints are confronted with each other through amethodology of sincere and constructive questioning(instead of discussing and trying to convince the otherthrough logical argumentation). The importance of ques-tioning and probing is founded in a moral epistemologi-cal viewpoint in which moral knowledge is never given,but emerges in a dialogical process. A dialogue can takeplace at different levels: at a concrete communicative levelin which the ethicist (i.e. facilitator or researcher) and thevarious stakeholders in a healthcare institute reflecttogether, and at a more abstract level between (ethical)theory and practice in which various kinds of knowledgeare confronted with each other. On the basis of dialogueit might become clear that a practice is wrong, or hasdeveloped a culture, structure and routine that should beimproved. Bioethicists may also draw such conclusionsthemselves and function as a critical watch-dog of wrong-ful practices. This function of bioethics will stay in placeand remain useful. Yet, from our point of view it seems to

be more effective to draw such conclusions with the fieldof practice and to take practitioners along in a process ofiterative improvements creating room and amplifyingcritical voices within that practice, and cherishing what isconsidered good. We do not want to overestimate ourpotential to improve practices, and we acknowledge thatin certain situations one is quite powerless to changethings for the better. We therefore concentrate on a fewpractices that reveal a need for improvement and engagewith them for a longer period of time.

Within inter-ethics, ethical theory and bioethics’ criti-cism do not have priority over the moral expertise andexperience of healthcare practitioners. Ethical theory andbioethics’ expertise and criticism is relevant and presentduring the whole dialogical process, not only in the begin-ning or at the end of a research project. Theories andcriticism, moreover, are used in a specific way. They arenot presented in an apodictic manner, but integrated intoa dialogical process, in which participants are invited torespond to the issues at stake. This means that weacknowledge the value of ethical theories developed inthe tradition of bioethics (e.g. principle based ethics, careethics, virtue ethics, etc.).18 For example, principle-basedethics has provided health care professionals with generalviewpoints on which they could build their professionalguidelines and codes of behaviour. Theoretical insightsfrom the canon of bioethics are extremely useful and wedeliberately and purposefully use these insights to deepenthe conversations among stakeholders in practices andjointly to analyse the acts and processes in the practicesunder consideration. The relevance of such theory,however, depends on whether it works for the variousstakeholders (including the biomedical experts) in a prac-tice and supports dialogical learning processes. Ifprinciple-based ethics is no longer able to support prac-titioners in interpreting their situation and developingshared normative perspectives, other forms of theory,such as care ethics, may be introduced to stimulate reflec-tion and learning. In earlier projects we have, forexample, introduced Nussbaum’s concept of tragedy toenhance the mutual understanding of the role of emo-tions in coercion in psychiatry.19 This concept enabled usto articulate the relevance of the communication aboutemotions (shame, guilt, sadness, anger) when using coer-cive measures. Practitioners recognized this idea but werenot able to find the words for their moral intuition thatcoercion is always problematic, but cannot always beprevented. This dilemma needs to find expression other-wise the negative sides of coercion for clients are

17 G.A.M. Widdershoven, T.A. Abma & B. Molewijk. Improving Careand Ethics: A Plea for Interactive Empirical Ethics. Am J Bioeth 2009(forthcoming).

18 Molewijk, op. cit. note 3.19 T.A. Abma, B. Molewijk & G.A.M. Widdershoven. Good Care inOngoing Dialogues. Responsive Evaluation and Moral Deliberation,Health Care Analysis, 2009; 17(3): 217–; T.A. Abma et al. DialogicalNursing Ethics. The Quality of Freedom Restrictions, Nursing Ethics,2008; 15(6): 789–802.



underestimated and ignored. Nussbaum’s work helped usto point out that when practitioners ignore ambivalentfeelings, chances to improve situations are lost. This criti-cal notion was translated positively into a set of qualitycriteria for coercion to motivate good care in psychiatry.So, from a dialogical viewpoint, norms for good actionand practice have to be found, articulated and reflectedupon in a mutual dialogue among all the participants inthat practice, including bioethical experts, with supportof the ethicist as facilitator, making use of existing moraltheories in an open and responsive way. Theory is thenused for practice and further articulated in confrontationwith practice.

From defending rights towards fosteringinterdependent practices of responsibility

Traditionally bioethics in Western liberal societies hasfocused on both the construction and the defence of legalrights. Freedom of choice is one of the fundamentalrights to which bioethicists refer in their work. Thisfreedom is legally anchored in national laws and interna-tional agreements. The protection of the freedom andautonomy of individuals, especially vulnerable groupssuch as patients, has been a prime goal within bioethics.Protection of patients and weak persons against the vio-lence of the state and medical experiments more in par-ticular is a driving force within the discipline and medicalethics committees.20

As part of a modern movement to control such vio-lence, bioethics has been at the forefront to develop uni-versal and rational ethical codes and protocols like thenotion of informed consent to protect citizens andpatients.21 Underlying is the idea that with these codesand protocols, there is less chance that practitioners willdisrespect the autonomy of individuals. While the prin-ciple of doing good used to be first, gradually the prin-ciple of respect for the autonomy for the patient gainedmore importance. In order to stimulate practitioners tobe more respectful of the patient’s autonomy, and toindividualize what is good, a set of cohesive codes ofmoral rules were developed and taught to practitionersfor example, through the education of medical ethics. Inorder to make sure that practitioners also applied ethicalcodes in practice, bioethics had to convince them thatfollowing such rules would be rational. Ethical codes

such as doing no harm and respecting autonomy weretherefore framed as universal principles to stimulate prac-titioners to use them, and appeared to be recognizable forpractitioners. Nowadays, for instance, we hear manynurses and doctors speak about respect for the autonomyof the patient. Yet the provision of universal principlesalso had unintended side effects, one of them being thatpractitioners sometimes routinely apply principleswithout actively thinking about the appropriateness ofthe principle within a certain context. We have alreadygiven the example of the doctor providing information toa patient in order to respect his autonomy, withoutchecking whether the patient actually has the capacity todecide. Even worse, principles may result in no longertaking responsibility for one’s deeds, as it might seemenough to follow the rules. As Bauman (1993) states:‘Individual responsibility is then translated as the respon-sibility for following or breaching the socially endorsed,ethical-legal rules.’22 So, while the aim was to providepractitioners with a clear set of guidelines framed as uni-versal principles, the application of such principles mighthave negative consequences, as they do not stimulatepractitioners to take the context of the situation carefullyinto account.

Furthermore, the traditional paradigm perceivedmedical doctors as potentially evil people who mightmore or less deliberately harm vulnerable patients or dis-respect their autonomy. Recently, doubts about thisscheme of evil and good have been raised.23 Distrustingdoctors seems inadequate and unfair, since they aremoral people like all other human beings; they aremorally sensitive and experienced. Likewise, it is patron-izing to treat each and every patient as being vulnerable,weak, and in need of protection. And as overarching andmutually shared frameworks, ideologies and grand nar-ratives have disappeared,24 it seems at least unrealistic toassume that all of us will just subscribe to the duties andrights that were once developed. This does not mean thatuniversal values have no role to play. They may inspireus, and for instance keep us aware of the need to treatother people in a way in which we ourselves would like tobe treated. Yet universal values will always have to becontextualized. What does justice or fairness mean in thisconcrete situation? To determine this, one needs to havethe capacity for practical judgment. If we lose confidencein the guiding capacity of grand narratives, room iscreated for taking up our moral responsibility again inrelationships with one another.25 This will enable us toclaim our morality and moral responsiveness, acknowl-edging that morality is essentially ambivalent. Personal

20 P.R. Wolpe. 1998. The Triumph of Autonomy in American Bioe-thics: A Sociological View. In Bioethics and society. Constructing theethical enterprise. R. DeVries, J. Subedi, eds. Upper Saddle River, NewJersey: Prentice Hall: 38–59; J.F. Childress. The Place of Autonomy inBioethics. Hastings Center Report 1990; 20: 12–16; R.R. Faden, T.L.Beauchamp, N.M.P. King. 1986. A History and Theory of InformedConsent. Oxford: Oxford University Press.21 Z. Bauman. 1993. Postmodern Ethics. Oxford: Basic Blackwell;Faden et al., op.cit. note 19.

22 Bauman, op. cit. note 20, p. 29.23 R. Rhodes. Rethinking Research Ethics. Am J Bioeth 2005; 5(1): 7–8.24 J.F. Lyotard. 1984. The Postmodern Condition. A Report on Knowl-edge. Manchester: Manchester University Press.25 Bauman, op. cit. note 20, p. 34.



morality is a prerequisite for ethical negotiation and con-sensus. Instead of trimming the individual’s moralresponsiveness by providing general and universal ethicalcodes and principles, we come to appreciate emotions, toacknowledge the ambiguities and ambivalences of humanbeings. ‘We can recognize the moral self by its uncertaintywhether all that should have been done, has been.’26 So,instead of helping people to choose one principle oranother in acute situations, it seems much more impor-tant to help people understand the ambiguity of theirsituation and to deal with the consequences of theirchoices, being aware of the interdependence with others.

New approaches have arisen that pay more attention,not just to abstract duties and rights, but also, andmainly, to the mutual responsibilities of people in reallife. While a legal approach takes duties and rights asgivens, an approach that fosters the practices of respon-sibility will help to articulate and attune normative expec-tations. Walker’s (1998) work on the practices ofresponsibility can serve as a source of inspiration inunderstanding and framing the processes of negotiationover the assignment of responsibilities. According toWalker, responsibility is essentially moral, expressingwhat we owe to others and whom we should care for.Thus, the other comes first; we are there for others, beforewe are with others. The question of what we owe toothers, and what we expect of ourselves and others, canand should not be answered in general or in absoluteterms. The answer depends on and is constituted by situ-ated narratives of identity, relations and values. Thesenarratives may vary and conflict and lead to misunder-standings between people. It is here that bioethics comesin; articulating the various normative expectations, theircontextual groundings in narratives of the self, relationsand values, and helping the parties involved to enter intoa conversation about their mutual expectations.27 Thisimplies that bioethicists first engage in conversations withindividuals and groups to understand empathically theirexpectations of themselves and others, and to increasetheir personal understanding of the responsibilities borneby themselves and others. Then the bioethicist will ideallyfoster a mutual process between individuals and groupsto enhance their understanding of the expectations ofothers, and to increase both the mutual understandingbetween groups and their capacity to adjust their expec-tations and responsibilities.

This focus on responsibility implies a new conceptual-ization of autonomy. Autonomy is not primarily related

to the idea of the individual, free and independent of(family) traditions and authorities, determining andchoosing whatever is important to him. Autonomy anddependence are not to be regarded as opposites but astwo sides of the same coin.28 Human beings are to beunderstood as in relationships, connected to each other.These relationships are both local and global. Throughmodern ICT we are part of many international commu-nities. We learn about individuals in other parts of theworld, and may change during these interactions. Due tothe increasing information, beginning with the massmedia, about the specific circumstances of other people,the exotic Other has increasingly been normalized andintegrated into our life world.29 The Other is our neigh-bour from next door or the threatened refugee. The Otheris visibly around, part of our identity. We have becomepopulated by many faces and people, more and more ableto walk in someone else’s shoes.30 Bioethics thus needs torefocus on ever changing social networks of people andhow morality is created within communities of practice.Bioethics gains a role in organizing a reflection on theshared moral understandings within a community ofpractice.

This implies that as bioethicists we have to contact andcommunicate with unique, multi-faced persons if we wantto understand their identity and values. In order to fosterprocesses of interculturality we should not start with afocus on cultural differences, but begin with the acknowl-edgement of shared human values and commonalities.From thereon we can examine the differences that matter,with an attitude of openness and respect that character-izes a good dialogue.31 Intercultural processes also chal-lenge us to think beyond frozen images and stereotypesbetween cultural groups and to engage in face-to-facecontacts to learn about each other, and develop morecomplex, inclusive perceptions of our fellow humans.This does not mean that we give up our own values(relativist position), nor that we take our own values forgranted (absolutist position). From a hermeneutic per-spective, dialogue means that we relate and engage withothers, learn from each other, and bring our own perspec-tives into play.

METHODOLOGICAL IMPLICATIONS

The primary aim of bioethical research in the traditionalsense used to be to generate and transfer knowledge (in

26 Bauman, op. cit. note 20, p. 12.27 T.A. Abma et al. Two Women with Multiple Sclerosis. ConflictingNormative Expectations between Patients and their Caregivers. NursEth 2005; 12(5): 479–492; M. Goldsteen et al. What Is It to Be a Daugh-ter? Identities under Pressure in Dementia Care. Bioethics 2007; 21 (1):1–12; B. Oeseburg & T.A. Abma. Care as a Mutual Endeavour. MedHealth Care Philos 2006; 9: 349–357.

28 C. Mackenzie & N. Stoljar. 2000. Relational Autonomy: FeministPerspectives on Autonomy, Agency and the Social Self. New York/Oxford: Oxford University Press.29 H. Oosterling. 2002. Radicale Middelmatigheid [Radical Medioc-rity]. Amsterdam: Boom.30 K. Gergen. 1991. The Saturated Self: Dilemmas of Identity in Con-temporary Life. New York: Basic Books.31 H-G. Gadamer, op. cit. note 12.



the form of principles/theory) about practice and make itapplicable to practice. If bioethics is to change along thelines sketched above, this linear model should be sur-passed. Bioethics should begin with the reality and com-plexity of practice and assist practitioners and otherparties in a process of practice improvement. The aim isnot to develop knowledge about a practice with a viewfrom the top, but to stand within that practice (theembedded bioethicist) and further develop the moralquality of the practice and the moral sensitivity andcapacity of the practitioners. A methodology thatmatches those ideas and fosters practice improvementthrough an embeddedness in that practice and interactionwith its practitioners has been developed in various dis-ciplines. Examples include participatory approaches inthe field of agricultural development in developing coun-tries and sustainable development.32 Furthermore, inter-esting examples can be found in the field of interactivepolicy making33 and responsive evaluation.34

An interactive methodology is responsive in that ittakes the issues of as many parties (stakeholders) as pos-sible as a starting point for ongoing dialogues. In the end,this does not exclude the ethicist and his/her moral theo-ries, as we will explore later, but the starting point is withthe experiences of practitioners. In an interactive meth-odology the design cannot be pre-ordained, since theissues of stakeholders cannot be known in advance. Aradical openness to the perspectives of the stakeholdersimplies that the design emerges gradually in conversationwith all parties. However, a basic ground plan of themethodology can be presented. The research process iscyclical and dialogical. This means that the input of oneparticipant or stakeholder group forms the input for theother participant/stakeholder group, so that information

gets redefined and deliberated during the process. Inorder to assist the various stakeholders to develop theirown understanding, first the issues will be investigatedand discussed by each stakeholder group, then the issuesof the various stakeholder groups will be brought into aheterogeneous dialogue.

Responsive research is multi-experiential, activelyusing the various experiences and knowledge bases of theparticipants in the process. The process starts with thestakeholder group with the least influence, in order togive them a ‘say’ in the process of practice improvement.In many instances professionals (doctors, nurses, thera-pists, researchers, managers, policymakers etc) havedetermined the policymaking process. Their wishes andpreferences are known and only need to be actualized.The experiences of patients and family members haveoften not been investigated systematically before andtherefore require extra attention. Through careful listen-ing and probing one will gradually gain an understandingof the questions and concerns of these latter groups, aprocess which is fostered when working with members ofthe group as co-researchers.35 Engagement of all stake-holders in the process implies frequent communicationwith their interest organizations, including patient orga-nizations. Preferably this collaboration starts immedi-ately with the writing of the research proposal and theformulation of the main objectives and questions.

Besides the identification of stakeholder issues, a dia-logue between stakeholders is an essential part of aninteractive methodology. A genuine dialogue implies thatparticipants change in the process; they will listen to eachother, learn about each other’s experiences and frustra-tions, and add new experiences to their existing reper-toire.36 Concrete experiences and stories are moreappropriate to foster this mutual learning process thanabstract knowledge.37 It is not very likely that profession-als will give up their own agenda when reading the issuesenlisted by patients. However, if they read or listen to thestories and uncertainties encountered by patients, andvice versa, and if both parties are enabled – in a face-to-face meeting or a virtual encounter – to ask questions, toprobe, to argue and to deliberate about their experiencesand opinions, this may lead to adjustments of existingprejudices and the development of ideas and solutionsthat cannot be traced or reduced to the existing ones. Thisprocess can be compared with the fusion of horizons;

32 K. Swaans, J. Broerse & J. Bunders. Agriculture and HIV/AIDS: AChallenge for Integrated and Interactive Approaches. Journal for Agri-cultural Education and Extension 2006; 12(4): 231–247; B. Kasemir, J.Jager, C.C. Jaeger & M.T. Gardner. 2003. Public Participation in Sus-tainability Science: A Handbook. Cambridge: Cambridge UniversityPress; M.C. Johnson, M. Poulin & M. Graham. Towards an IntegratedApproach to the Conservation and Sustainable Use of Biodiversity:Lessons Learned from the Rideau River Biodiversity Project. Hum EcolForum 2003; 10(1): 40–55.33 P.P.J. Driessen, P. Glasbergen & C. Verdaas. Interactive Policy-making: A Model of Management for Public Works. Eur J Oper Res2001; 128: 322–337; W.J.M. Kickert, E.H. Klijn & J.F.M. Koppenjan.1997. Managing Complex Networks. Strategies for the Public Sector.London: Sage.34 E.G. Guba & Y.S. Lincoln. 1989. Fourth Generation Evaluation.Beverly Hills; J.C. Greene & T.A. Abma, eds. Responsive Evaluation.New Directions for Evaluation 2001; 92: 1–105; R.E. Stake. 2004.Standards-Based and Responsive Evaluation. Thousand Oaks, CA: Sage;T.A. Abma & G.A.M. Widdershoven. Sharing Stories: Narrative andDialogue in Responsive Nursing Evaluation. Eval Health Prof 2005; 28:1: 90–109; J.C. Greene. 1997. Participatory Evaluation. In Evaluationand the Post-modern Dilemma. Advances in Program Evaluation. L.Mabry, ed. Greenwich: JAI Press, 171–189.

35 T.A. Abma, C. Nierse & G.A.M. Widdershoven. Patients asResearch Partners in Responsive Research. Methodological Notionsfor Collaborations in Research Agenda Setting. Qual Health Res 2009;19: 401–415.36 G.A.M. Widdershoven. Dialogue in Evaluation: A Hermeneutic Per-spective. Evaluation 2001; 7(2): 253–263.37 Abma & Widdershoven, op. cit. note 33.



participants extend their perspective, broaden theirhorizon.38

A responsive, interactive methodology requiresadequate social conditions, including openness, respect,trust and engagement of all stakeholders. These condi-tions are not always in place, and need to be activelycreated and maintained throughout the whole process.For instance, deliberate attention should be paid to asym-metric relationships and subtle processes of exclusion.Moreover, a dialogical ethics implies that what, exactly,is understood as openness, respect, trust and engagement,is not known beforehand. Within a responsive method-ology inspired by a dialogical ethics, researchers andethics facilitators are continuously alert to what thesemoral concepts mean in the concrete situation and rela-tion, and how they are constructed and used. The key tothe creation of good social conditions is open, respectfuland frequent, informal communication with all stake-holder groups. Face-to-face communication – rangingfrom informal contacts by telephone and email, partici-pation at meetings and conversations via interviews andfocus groups – is most appropriate. This form of commu-nication enables participants to engage in the process, togive advice, to negotiate and to deliberate with eachother. How the design achieves concrete form will vary,and the main methodological decisions concerning thedesign will be negotiated with relevant stakeholders timeand again. Those decisions include, for example, theselection of participants and the choice of appropriatemethods and techniques.

Since the process should be fair, giving each stake-holder group a say, the collaboration between partiesrequires an independent process facilitator who createsthe conditions for successful participation and dialogue.Independent means that the facilitator has no stake in thecontent of the outcome. This does not mean that thefacilitator has no interest; he is primarily motivated notto reach a specific solution, but to help the participants tocome to a common view. The facilitator requires inter-personal skills and knowledge of group dynamic pro-cesses. The facilitator should be able to develop amultiple partiality; each stakeholder group should beunderstood. One should not be considered an advocate ofpatients in a dialogical process; this will prevent theengagement of other stakeholders. A multiple partialityenables the facilitator to act as a teacher; he can help toexplain the different perspectives to the various stake-holders. Since stakeholders may tend to re-establish theirown perspectives, the facilitator should be able to act as aSocratic guide, questioning certainties and taken-for-granted assumptions.39 At the same time the facilitator

will – when consensus is absent – act as a mediator andhelp to create mutual agreement. A process facilitator isnot only responsible for the process, he will also keep aneye on the meaningfulness of the dialogues. Substantialknowledge is required to be able to ask the right questionsand to value the substantial quality of the dialogicalprocess.

CASE STUDY: INNOVATION OFELDERLY CARE

In order to make our views more concrete, we will presenta case example. We will first present the project and thereasons why this project came into existence. Then we willhighligh specific features of this project and our proce-dures in order to explain why this project is different frommore traditional bioethics projects. Finally, we will drawsome conclusions regarding the future of bioethics asinter-ethics and what is needed in order to fulfill theagenda of inter-ethics.

The project

In Dutch society, the number of older people is rising.This raises new challenges for elderly care. How canhealthcare provisions be adapted to the needs of agrowing number of people, who live longer in their ownhomes, needing more support with social and medicalissues? In order to find new ways of dealing with theseproblems, a project was started in the region of South-Limburg in the Netherlands. This region shows thelargest growth in elderly population in the Netherlands.Various parties (local politicians, care providers, patientgroups) recognized the need for a change in healthcare toaccommodate this development, and supported theproject. The aim of the project was to create a networkbetween healthcare scientists, healthcare providers,clients and policymakers in order to develop an agendaand a network for innovations in elderly care. The projectteam was mixed and consisted of Vivianne Baur (a cul-tural scientist) who carried out the research work underthe direct supervision of Guy Widdershoven (a bioethi-cist), and a group of scholars with a background in ger-ontology, psychiatry, nursing home medicine andnursing. The project started in February 2007. In May2008 the project ended with a final report,40 and a knowl-edge centre for the innovation of elderly care was for-mally institutionalized.

The project consisted of several phases. It started witha series of in-depth interviews: 13 interviews with older

38 H-G. Gadamer, op. cit. note 12; G.A.M. Widdershoven, op. cit. note35. G.A.M. Widdershoven & T.A. Abma, op.cit. note 13.39 T.A. Schwandt, op. cit. note 9.

40 V. Baur et al. 2008. Academisch Centrum ZorgInnovatie Ouderen.EindRapportage. [Academic Center CareInnovation Older People. FinalReport.] Maastricht University.



persons and representatives from patient groups in theregion and 18 with healthcare professionals. Questionsincluded the following: What problems do they experi-ence? What solutions do they see? What do they expectfrom a network? What barriers do they foresee? The nextphase consisted of one homogeneous focus group withresearchers (25 participants), one focus group with rep-resentatives of older people (11 participants), and onefocus group with caregivers (6 participants). In thesegroups participants were invited to interpret the resultsfrom the interviews, and to prioritize issues for researchand innovation. In the last phase, an exchange about thestakeholder issues (while paying attention to underlyingexperiences) was organized in a dialogue group; this wasa heterogeneous/ mixed group with representatives of allstakeholders (25 participants). Furthermore two meet-ings were organized with a steering committee, at thestart and finish of the project. During a period of oneyear, an agenda for innovation and research was devel-oped. This agenda should serve as a frame for futureprojects.

At the start, the problems defined by various stake-holders were quite different. Older people identifiedloneliness and safety as issues of concern. Care providersfocused on more specific diagnoses (dementia), onpatient-centred care and on the role of various disci-plines (especially that of the GP). They were also con-cerned about the labour force (would there be enoughnurses to organize work in the future?). Care researchersfocused on frailty, mobility, multi-morbidity, and dis-ability management. These different views were madeexplicit in the homogeneous focus groups. Throughexchange in the dialogue group, the various stakeholderscame to understand one another better, and new con-cepts were developed which were appealing to allgroups. The concept of quality of life replaced andunited issues like loneliness, safety, patient-centred care,and mobility. The focus was broadened from medicalcare to cure, care and social participation. The conceptof disability management was broadened to integratedcare through all aspects of life. These three new conceptswere the core of the agenda for innovation and researchand would serve as criteria for research and practice-improvement projects.

Apart from setting an agenda for innovation andresearch, the project resulted in establishing a regionalnetwork in which parties agreed to work together oninnovations in care, along the developed lines. Theystarted developing innovations, with the participation ofall parties, and applying for funding in the nationalprogram for innovation of elderly care, set up by theMinistry of Health, based on input from our local expe-riences. Meanwhile, this has proven to be very successful.Both a basic funding of the network and a large proposalfor the innovation of care have been granted.

Inter-ethics in this project

What made this project an example of an inter-ethicsapproach? First of all, older people played a central role.Through interviews and a homogeneous focus groupwith (representatives of) older people, issues were put onthe agenda. At all stages, older people had a strongvoice. They were able to influence the definition of theproblem. After a discussion started by the elderly asso-ciation, the participants in the network decided tochange their way of speaking about the problem. In linewith international literature, care researchers and careproviders commonly used the notion of frailty. The rep-resentatives of older people argued that this term madethe older people into objects with certain characteristics(like being frail). They proposed to rephrase this into:‘older people in a frail situation’, thus focusing on thecontext. This proposal was accepted by all parties, sothat the texts became somewhat longer, but also more inline with the shared view that the problem should not beindividualized, and that one should be open to the dia-lectic of the situation: although the context may be lessfavourable, this is not to say that older persons have noways of coping with it.

Older people also had a strong input when the networkwas established and the network participants set up con-crete innovations. It was decided that only innovativeprojects would be developed which actually address needsas experienced by the elderly. Already in the brainstormphase, representative groups of older people were part ofthe meetings in which the goals of the projects were dis-cussed. During one such meeting, care providers pro-posed to create a new institution for patients who hadrecovered enough to leave the hospital, but were not wellenough to go home. The older participants were not infavour of this, because they saw a greater need forimproving care in the hospital first. They agreed to thinkit over before the next meeting. At the next meeting, theyreported having discussed the issue with other elderlygroups, which had resulted in a stronger argument fortheir prioritization of the care process in the hospital. Atthe meeting, it was decided to develop the project asproposed by the older people’s representatives first and ifpossible to integrate elements of the other project. Duringthe further process of writing and discussing the pro-posal, it turned out to be possible to integrate bothprojects. If the older people had not been so clear in theirviews and active in the meeting, the outcome would cer-tainly have been different. These examples show thatolder people during the process have been able to developa crucial role in the project, and to have real influence inmajor issues.

Although there are not many older people withdifferent ethnic backgrounds in this particular region ofthe Netherlands, deliberate attention was paid to the



consultation of these people. One interview was con-ducted with a representative of the Platform of migrantclients. Two members of this platform attended the dia-logue group. Due to their participation, special attentionwas paid to the issue of diversity, not only in terms ofcultural differences but also in terms of education, SES,housing situation and needs. The input of these represen-tatives engendered the idea that it is impossible to speakof ‘the’ older client, and that the particular needs of indi-viduals have to be investigated each time. It was a clearmessage to the network to keep an eye on the issue ofdiversity within the project proposals.

A unique issue was the integration of care, science andpolicy. Often, these areas are separated from one another,since they have different aims and issues of concern. Inour project, we were able to bring people from variousbackgrounds together, thereby creating hybrid outcomes.Although this was not an easy process, because it takestime to understand each other and to find commonground, the result was stimulating, in that newapproaches to elderly care were developed, making use ofexperiences of all parties concerned. During the process,it was often difficult to make participants open towardsand learn from one another. When the concrete experi-ences of the representatives of older people were taken asa starting point, their embodied stories gave way to amore open communication between the stakeholders.Focusing on concrete facts and experiences preventsstakeholders from presenting only their views or theorieson certain issues. Starting with practice allowed the inter-ests and normative positions of different stakeholders tobecame more open to one another. The stories of theolder people thus became a vehicle for learning: the com-munication between the stakeholders changed from astrategic debate between researchers and policymakers toa dialogue in which the experiential knowledge of olderpeople made an appeal to the stakeholders to look forshared values.

The process of prioritization of research topicsrequired much tact and patience, not only from the mod-erator of the discussion, but also from the participants. Aresponsive methodology was chosen for the prioritizationprocess. Interviews with all the stakeholders took place;homogeneous groups were organized (one with represen-tatives of older people, one with researchers, one withpolicymakers and care providers). The homogeneousgroups aimed at deepening the stakeholders’ issues thatarose in the interviews. Further, the homogeneous groupsfunctioned as a preparation for these diverse stakeholdersto enter into heterogeneous dialogue with each other.During the heterogeneous dialogue, in which representa-tives of all three groups of stakeholders were present, theresults of the homogeneous groups were used as input. Inorder for the meeting to become interactive and dialogi-cal, the stakeholders were divided in little brainstorm

groups in the room, each of which consisted of represen-tatives from the three stakeholder groups. These sub-groups had a brainstorm about some issues that had beenput on the agenda beforehand by the stakeholders in thisheterogeneous dialogue meeting. The participants wereasked to think about innovative ways to improve theissues being discussed and to make use of each other’sexperiential knowledge. This was a fruitful way for theparticipants to go into dialogue with a concrete goal in asmall setting that enhanced the input of all participants.After that, the results of the brainstorm groups werediscussed in plenary setting again, leading to a broaderdialogue with all stakeholders in the room and the settingof the agenda of the network, based on a shared andmultidisciplinary understanding of what is important forolder people in a frail situation. Thus, at the end of thisdialogical process, people knew and trusted each otherenough really to listen to each other and to be prepared tochange themselves. Caregivers became concretely awarethat the elderly can have different views, researchers hadto acknowledge that people in practice may know betterwhat is relevant and useful, policymakers saw that theyneeded to be less strict with rules and regulations (forinstance concerning payments arrangements for care) sothat experiments would be possible, and the representa-tives of older people learned that it was possible to worktogether with researchers, policymakers and caregivers ina constructive and concrete way, without having to fightto have a voice.

From the outset, we (the project team) did not play thetraditional role of the bioethicist as experts. We had somebioethical notions in our mind, like focusing on the needsof patients and looking at ways to improve the careprocess (both notions stemming from care ethics). Wewere also interested in the values of participants in theproject: what did they see as important in life, and howdid they see their role as (potential) patients and profes-sionals? Yet we did not measure such values against nor-mative principles and theories. We focused on helping theparticipants to articulate the values in their practice, todevelop these values themselves, and to find new values inmutual dialogue. Thus, we did not judge the practicefrom an external point of view but helped to improve it byfacilitating interactions. Our role was to foster theprocess, to raise mutual understanding between partiesand to create room for those less heard in the policyarena. We were not standing outside the practice, bring-ing in external norms, but were partners in the dialogueabout the practice, drawing normative conclusions fromhermeneutic dialogues. One of these normative conclu-sions was that the parties should first find a commonground and a shared general interest – here the desire toimprove the quality of care for older people – before theycan start to collaborate. This conclusion includes theidea that the parties should sometimes place their own



interests between brackets. These normative conclusionswere not derived from theory but grounded in practiceand articulated by the facilitators.

We did not focus on rights and duties but helpedparties to express the responsibilities they expected fromone another. The older people spoke up for themselves,not by claiming rights but by referring to the responsi-bilities of professionals, for instance being responsiblefor helping them not to get lost in the hospital. Whileresearchers were initially concerned about their ownprofile and research lines, and care providers about theirstrategic position, these parties gradually opened up,redefining their responsibility in terms of a sharedresponsibility for the well-being of older people in theregion. This opened the way for collaborative researchprojects and themes that were the outcome of interac-tions between the stakeholder groups. Caregivers andresearchers made clear how they saw each other’sresponsibilities (in doing research that would reallyimprove care, and in changing care arrangements in linewith scientific evidence). During the process, the bound-aries between care and research became less strict. Car-egivers became involved in research projects, andresearchers worked together with professionals toimprove care.

This also meant that roles and identities became moreflexible. The role of the scientist was no longer distant andobjective; the role of professionals no longer intuitive andsubjective. Likewise, the traditional distinction betweenthe helping professional and the dependent older personwas deconstructed. Professionals realized they needed toknow the experiences of the elderly to improve their prac-tice; the elderly became a powerful party (even able todefine the aim of a whole project, as we saw above).Participants came to regard themselves as part of agroup, acquiring a new sense of identity and power. Thiswas clearly so for the older people and representatives ofpatients, who organized their own meetings. But caregiv-ers and professionals also learned from their direct col-leagues and saw their experiences and goals as part of agroup, rather than as individual.

In the project, we used a responsive methodology. Westarted with those who had the least power, the olderpeople. We made explicit their experiences and viewsthrough interviews, which were used as input for thehomogeneous focus groups. We made use of the prac-tical knowledge of the participants, focusing upon theirexperience. Finally we organized a dialogue, in whichthe parties were able to learn from one another.Although we planned these steps beforehand, we had toadjust the process several times, organizing extrainterviews or group meetings when the need came up(felt both by us and by the participants). Thus, thedesign was emergent, and adapted to the concretesituation.

DISCUSSION

Our view of the future of bioethics is not merely based ontrends in society. The claim that bioethics will have toadapt to societal changes is not neutral. We regard thedecline of grand narratives, the rise of interdependencypractices and the growing diversity in society as desirable,and see a positive role for bioethics in fostering thesedevelopments. In our view, an embedded, interactiveapproach will make bioethics not just better fitted tocurrent and future social developments, but also moreadequate in both a theoretical and a normative sense.

This position is grounded in the following consider-ations. In the first place, an embedded approach to bio-ethics recognizes practical rationality. Practice is a sourceof innovation, and the connection with practice willenhance the utilization of bioethical research. This utili-zation of bioethical knowledge is conceived as a processof mutual enrichment of ideas and values between prac-tice and theory, improving both theoretical and practicalnormativity. Secondly, our conception of inter-ethics rec-ognizes that moral knowledge and moral questions startwith experience. Understanding the meaning and feasi-bility of theoretical notions requires concrete experienceand insight into the context. Moreover, we only know ifmoral knowledge and the answers to moral questionswork, if we deal with them in practice and with practitio-ners. Thirdly, the input of healthcare professionals,patients and other actors in bioethical research projects isdesirable, since they are considered to be the end-users ofsuch knowledge. From a democratic perspective, theyshould have a say in those processes that touch upon andmay have an influence on their interests and the thingsthey value. Fourthly, the methods used in inter-ethics aredialogical and responsive.41 This feature of inter-ethics ismore than just practical and efficient. It is based on anepistemological view on how moral insight and knowl-edge grow and how processes of meaning-making work.Through a dialogue with involvement, misunderstanding,disagreement, emotions, contextual contingencies such aslimited time and place, viewpoints emerge and acquiremeaning. Finally, an engagement with practice is not onlypractical and efficient, but also enriching and creative.Inter-ethics will lead to innovation and new knowledge asvarious experiences and disciplines come together and areintegrated.

One might question whether the hermeneutic view,with its focus on context and interdependency, is notitself one-sided, neglecting the trend towards scientificrationality that is characteristic of our society in general,

41 Widdershoven et al., op. cit. note 3; T.A. Abma, B. Molewijk &G.A.M. Widdershoven. Good Care in Ongoing Dialogues. ResponsiveEvaluation and Moral Deliberation. Health Care Anal 2009; 17(3):217–235.



and healthcare in particular. Will the trend towardsevidence-based medicine in healthcare practices (medi-cine, nursing, policymaking, bioethics) not undermine theprocess of practical reasoning? Will the pressure on prac-tices to be based upon evidence, rational analysis, notionsof efficiency and effectiveness not be detrimental to theidea of practice as wise judgement? Or, vice versa, doesnot the reliance on practical reasoning imply a disregardof science and evidence? In our view, evidence basedmedicine and practical rationality are complementary.Evidence based medicine and policy, by reducing uncer-tainty, have vastly improved patient care and healthpolicy. Yet they will never be able to remove all complex-ity and uncertainty. The gap between constant, reliable,universal laws and variable manifestations of illness in aparticular patient or moral dilemmas in a particularsetting remains. Science itself cannot control all factorsrelated to health and illness, nor can it solve all moral andpolitical issues within our societies. Appreciation of prac-tical reasoning will provide both healthcare professionalsand bioethicists with a human and fallible but still trust-worthy authority, not against scientific knowledge, but asa necessary complement to it.

Another issue for discussion is whether people arecompetent and willing to reflect on their practices. Canthose who are part of a practice judge themselves? Canethicists who engage with a practice also be critical? Acritical stance requires self-reflection and dialectical pro-cesses between people and groups. Not all professionalsare naturally engaged in critical conversations with theirfellows. In case of criticism, professionals may start adebate or discussion in order to convince each other. Insuch cases, there is no room for dialogue and a sinceremoral inquiry on the subject at hand. Furthermore, theymight tend to deny criticisms from patients, not takingthis feedback seriously. Innovations and quality improve-ments are not easily realized in a professional organiza-tion.42 Processes of group thinking, in which the groupdynamic is such that people do not accept deviant viewsor do not dare to criticize colleagues with more profes-sional knowledge or hierarchical power, may hinder theprocess of joint reflection on a practice. Group thinkingmay also apply to the ethicist who engages with practice.Human nature also implies that people develop blindspots and tend to take certain values and norms (concret-ized in working routines) for granted; thus we need dia-logue to become aware of our own limited rationality andto place our viewpoints in perspective.

The psychological processes and dynamics sketchedabove should not be denied and should be deliberatelyaddressed and tackled by those organizing interactive

processes of practice improvement. A dialogical inter-ethics requires the sincere input of different viewpoints; italso requires the empowerment of those who lack (orthink that they lack) an equal input. In a moral dialogue,every stakeholder has an equal say. One way to realizethis empowerment of all stakeholders, is by deliberatelyorganizing a cyclic process of data collection and analysisin which all stakeholders groups have the opportunity togive feedback on the results, and thus to correct the inter-pretations of others. Heterogeneous group sessions, inwhich various stakeholders engage in a conversation,bringing different perspectives to the fore, also help toprevent biases. Furthermore, the ethicist as process facili-tator should be prepared to challenge taken-for-grantedassumptions and habitual ways of thinking in practice,and be open to the risk of being attracted to them.Probing and challenging participants, and articulatingtensions are part of the role of Socratic guide. The ethicistcan question existing notions from his own perspective,and this may include a critical examination of their ideas.This, however, is not an external critique but the start ofa dialogical learning process, in which both the ethicistand the practitioners change.

This brings us to the role of ethicist, and his knowledgeof ethical theories. What is the use of theoretical notions,in the interactive processes of practice improvement?From an interactive perspective, theory may serve as abackground in the formulation of the research questionand guiding notions. In analyzing the data, the ethicistwill make connections with theoretical issues anddebates. Theory might thus be used as a tool to makeexplicit crucial elements in the experiences of partici-pants, and to show them in a more general light. Ethicaltheory can also be used to criticize current practice, usingit as a (but not the) source of knowledge or critical think-ing within the dialogue in practice and as a way to reflecton the position of the embedded ethicist. Our view oninter-ethics entails, that the critical role of the ethicistremains important, and even becomes stronger, in thecontext of a genuine dialogue. Open and respectful listen-ing and questioning are conditions for a true understand-ing of the meaning and relevance of both practice andmoral theory. This way of using moral theory in a criticalway is in line with the ‘ethics facilitation’ approach ofclinical ethics consultants in which the ethicist uses hisconceptual and critical framework from moral theory(and legislation, professional guidelines etc.) in order tobuild an inclusive consensus-building process.43

42 H. Mintzberg. Structures in 5s: A Synthesis of the Research onOrganization Design. Management Science 1980; 26(3): 322–341.

43 American Society for Bioethics and Humanities (SHHV-SBC TaskForce on Standards for Bioethics Consultation). 1998. Core Competen-cies for Ethics Consultation: The Report of the American Society forBioethics and Humanities. Glenview, IL: American Society for Bioethicsand Humanities; M.P. Aulisio. Ethics Consultation: Is it Enough toMean Well? Healthcare Ethics Committee Forum 1999; 11(3): 208–217;M.P. Aulisio, R.M. Arnold & S.J. Youngner. Health Care Ethics



The outcome of the dialogical process in which moraltheory plays a role, may entail general rules or prescrip-tions, which go beyond concrete experiences. The guide-lines can be clarified by referring to ethical theory, not asa foundation, but as a conceptual framework that cansituate and inform them, and in turn ethical theoryderives meaning from its interactive use in practice andfrom the experiences involved in that practice. In the caseexample, notions from care ethics guided the researchprocess. In the formulation of the research agenda, con-crete issues were gathered under more general concepts,such as quality of life and integrated care. When theseconcepts were later used as a basis for developing inno-vations, again connections were made to care ethics. Theethicist was not acting as an expert or consultant provid-ing practitioners with prescriptions on how to solvemoral dilemmas. He acted as a facilitator of the dialoguesbetween parties and supported the process of drawingnormative conclusions with and within practice.

CONCLUSION

In this paper, we have argued that in order to be ready forthe future, bioethics should develop in congruence withsocietal changes, making use of the insights of empiricalethics and research on experiential and organizationallearning. In this approach, theoretical and critical ele-ments of traditional bioethics play a role, as they can beused as tools in practical learning processes. Likewise,dialogues in practice can provide a basis for developingtheoretical knowledge. Within inter-ethics, the emphasisis on interactive processes of practice improvement,acknowledging interdependent relationships of responsi-bility. In such processes, bioethics becomes intertwinedwith healthcare practice, science and politics. Bioethicistswill have to refrain from judging practice from an exter-nal position. They will have to become engaged ininnovations in healthcare, taking responsibility forimprovement of practice, not by leading the way but bystimulating participants to reflect upon their values, rela-tionships and identities, and developing new ways ofdealing with practical issues by interaction and joint

learning. As the example showed, this involves manypractical activities: doing interviews, organizing reflec-tion and dialogue in and between groups. For sure, thisnew approach to bio-ethics will encounter new theoreticaland methodological challenges that will have to be dis-cussed among ethicists and other participants. Such dis-cussions should be based on practical bioethicalexperience and refer to that, as we did in our case study,in order not to become abstract debates. This means thatbioethics itself should become dialogical and process-oriented, using the dynamic differences between partiesand positions as the starting point for the development ofvalue commitment and responsibilities. The future of bio-ethics lies in engaging with practice; the future of bioet-hicists in becoming partners in and facilitators ofdialogue, contributing to practice improvements inhealthcare.

Tineke A. Abma is Professor at the Department of Medical Humanitiesand the EMGO+ Institute for Health and Care Research, VU Univer-sity Medical Centre, Amsterdam. Formerly she worked at the institutefor Healthcare Policy & Management at the Erasmus University and inthe department Health, Ethics & Society at Maastricht University. Shepublished extensively in the fields of program evaluation and researchmethodology, patient participation, organization learning and(nursing) ethics. Chronic care, psychiatry and elderly care are her mainfields of practice.

Vivianne Baur is a PhD student at the Department of Medical Humani-ties and the EMGO+ Institute for Health and Care Research, VUUniversity Medical Centre. Her research focuses on the interactive par-ticipation of older people in practice improvements and policy planningwithin residential care settings. She works to enhance dialogical ethics inelderly care practices, starting from a transformative researchparadigm.

Bert Molewijk is an assistant professor and works as program directorof Moral Deliberation and Clinical Ethics at the Department of MedicalHumanities and the EMGO+ Institute for Health and Care Research,VU University Medical Centre, Amsterdam. He recently co-edited the-matic issues on empirical ethics (Bioethics) and moral deliberation(Tijdschrift voor Gezondheid en Ethiek), and has published severalpapers on the theory, practice and training of moral deliberation (e.g.Health Care Analysis, 2009). His main interests are the practice andtheory of moral deliberation, moral competence, clinical ethics, andempirical ethics.

Guy A.M. Widdershoven is professor of Philosophy and Ethics of Medi-cine and Head of the Department of Medical Humanities at VU Uni-versity Medical Centre, Amsterdam, and senior researcher at theEMGO+ Institute for Health and Care Research at the same university.He has published on hermeneutic ethics, and its application in empiricalethics, moral deliberation and the ethics of chronic care (psychiatry andelderly care). He is scientific director of the Netherlands School ofPrimary Care Research (CaRe) and president of the European Associa-tion of Centers of Medical Ethics (EACME).

Consultation: Nature, Goals, and Competencies. A Position Paperfrom the Society for Health and Human Values- Society for BioethicsConsultation Task Force on Standards for Bioethics Consultation. AnnIntern Med 2000; 133(1): 59–69.



inter-ethics: towards an interactive and interdependent bioethics

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