Prompted by recent comments on the moral authority of dialogic consensus, we argue that consensus, specifically dialogic consensus, possesses a unique form of moral authority. Given our multicultural era and its plurality of values, we contend that traditional ethical frameworks or principles derived from them cannot be viewed substantively. Both philosophers and clinicians prioritize the need for a decision to be morally justifiable, and also for the decision to be action-guiding. We argue that, especially against the background of our pluralistic (...) society, it is only via unforced dialogue and properly founded argumentation, aiming for consensus, that we can ascribe rightness or wrongness in a normative fashion to dilemmatic situations. We argue that both the process of dialogue, properly constituted, and the consensual outcome itself have moral authority vested within them. Finally, we argue that the consensual decision made is able to withstand moral scrutiny and is action-guiding, without claiming absolute moral authority in other contexts. (shrink)

The historical emphasis of medical ethics, based on substantive frameworks and principles derived from them, is no longer seen as sufficiently sensitive to the moral pluralism characteristic of our current era. We argue that moral decision-making in clinical situations is more properly derived from a process of dialogic consensus. This process entails an inclusive, noncoercive, and self-reflective dialogue within the community affected. In order to justify this approach, we make two claims—the first epistemic, and the second normative. The epistemic claim (...) follows from Habermas’ “ways” of knowing. We argue that the dialogue emanating from this episteme focuses on the relevant facts about the patient, as well as on the values attached to these facts, thus allowing facts and their meanings to serve as the basis for reflective action appropriate to the circumstances. The normative claim follows from Habermas’ discourse theory of morality and communicative action. It determines that clinical decision-making should be approached from the perspective of the actual reality of people in their situation of illness, set in their socio-cultural background, and hence be grounded in the second-person perspective. Relocating ethical decision-making from a monological space into one characterized by dialogue is especially appropriate to the clinical encounter. (shrink)

The organisation of health care is rapidly changing. There is a trend to move away from individual health care institutions towards transmural integrated care and interorganizational collaboration in networks. However, within such collaboration and network there is often likely to be a pluralism of values as different health care institutions often have very different values. For this paper, we examine three different models of how we believe institutions can come to collaborate in networks, and thus reap the potential benefits of (...) such collaboration, despite having different moral beliefs or values. A first way is the pragmatic way in which the different health care institutions avoid ethical reflection and focus on solutions. A second possible route is that of consensus where health care institutions base their collaboration on values that they all share. The third, and final, approach is that of compromise. Although moral compromise is often seen in a negative light, we argue that in many cases compromise might be necessary and ethically justified. In a final section, we will shift our focus from discussing various theoretical methods to allow collaboration to the potential content of consensus or compromise. (shrink)

The aim of the paper is to reconsider Habermas’ discourse approach in terms of its usefulness in the realm of public healthcare where, on a microscale, intersubjective communicative situations arise between defined participants, i.e., patients and healthcare providers, patients’ family members, and further eligible contributors to patient-related decision making. A need for more “communicative interaction,” and explicative and practical discourse, is illustrated by two empirical examples of medical decision making which reveal both communicative and discursive deficits. To empower and enable (...) the patient as a rational and autonomous speaker and discourse participant, a Habermasian emancipatory argument and ‘the power of the better argument’ is recalled. The possibility of equal communicative and discursive rights in the light of real inequalities is discussed in the context of a ‘competence gap’ between participants. Further sections focus on the importance of informed consent on the side of the patient and the communicative competences as an important factor of healthcare system. (shrink)

BackgroundVascular surgery offers a range of treatments to relieve pain and ulcerations, and to prevent sudden death by rupture of blood vessels. The surgical procedures involve risk of injury and harm, which increases with age and frailty leading to complex decision-making processes that raise ethical questions. However, how vascular surgeons negotiate these questions is scarcely studied. The aim was therefore to explore vascular surgeons’ moral reasoning of what ought to be done for the patient.MethodsQualitative, semi-structured interviews were conducted with 19 (...) vascular surgeons working at three Swedish university hospitals. Data were analysed according to systematic text condensation.ResultsThe surgeons’ moral reasoning about what ought to be done comprised a quest to relieve suffering and avoid harm by exploring what is reasonable to do for the patient. Exploring reasonableness included to shift one´s perspective from the vessels to the whole person, to balance patient’s conflicting needs and to place responsibility for right decision on one´s shoulders. The shift from blood vessels to the whole person implied gaining holistic knowledge in pondering of what is best, struggling with one´s authority for surgery through dialogue, and building relationship for mutual security. To balance patient’s conflicting needs implied weighing the patient’s independence and a sense of being whole against ease of suffering, respecting the patient’s will against protecting life and well-being, and weighing longer life against protecting the present well-being. Finally, to place responsibility on one´s shoulders was conveyed as an urge to remind oneself of the risk of complications, withholding one’s power of proficiency, and managing time during the illness course.ConclusionsThis study contributes to uncovering how moral reasoning is embodied in the vascular surgeons’ everyday clinical discourse as a tangible part of their patient care. The results underpin the significance of moral considerations in the assemblage of medical knowledge and technical skills to further understand vascular surgeons’ clinical practice. The clinical application of these results is the need of forums with sufficient possibilities for articulating these important moral considerations in everyday care. (shrink)