Ethical relations and dialogue ethics, connecting themes in Vilhjálmur Árnason’s work on Icelandic sagas, public deliberation, and encounters between patients and professionals

^{Henrik Lerner}

Department of Health Care Sciences, Marie Cederschiöld University, Stockholm, henrik.lerner@mchs.se

This paper will explore two strands of Vilhjálmur Árnason’s extensive body of work: his analysis of dialogue ethics within medical ethics and his analysis of ethics in the Icelandic sagas. The central thesis is that combining these two strands, bioethics and literary analysis, can provide valuable insights to further the discussion of ethics among citizens in multicultural communities.

Vilhjálmur’s¹ analysis of the Icelandic sagas shows that the sagas have a specific value foundation, specific virtues as well as narrative in how to present the ethical aspects. In the field of bioethics, he has developed the study of dialogue ethics in several aspects, such as between patient and professional, in interdisciplinary research, and in public deliberation. By integrating insights from historic literary studies with contemporary bioethical research we gain an interesting platform for a discussion on Western assumptions of what constitutes a good dialogue. One of the core aspects in dialogue ethics is how to develop the procedure for a fair, open-minded, and oppression-free discussion in ethical issues. Vilhjálmur’s contributions are summarized here, but could they also be extended beyond the Icelandic and Western horizon?

I will compare his ethical framework to a recent parallel discussion on the claims of indigenous peoples for a fair dialogue. That is, a dialogue that must be inclusive with a carefulness about deciding the foundation of inherent values and the procedure of how to perform the dialogue. Finally, I draw conclusions on what dialogue ethics will gain from this explorative work.

 

Keywords: dialogue ethics, one health approaches, Indigenous peoples, bioethics, interdisciplinarity, ethics in the Icelandic sagas, medical ethics, literary analysis, multicultural communities

 

Introduction

Ethics is one of the oldest sciences existing and public deliberation of ethics has been recorded since the oldest written sources. For example, the Greek version of dialogue, most elaborated in Plato’s dialogues, took place in the public sphere. The procedure for such dialogues was primarily a kind of argumentation analysis, which used contradictions and opposite views in order to clarify a position that was considered fruitful (Ryle, 1965). There were also accounts of these dialogues being performed in front of audiences, where the audience was allowed to decide which proponent was the best (Ryle, 1965: 49).

 

Today, when we discuss dialogue ethics, we refer to a modern procedural strand of ethics, the origin of which is ascribed to Karl-Otto Apel and Jürgen Habermas (Benhabib, 1992). In their view, an ethically fair procedure for ethical discussions within the community is opted for and the question of justification is whether the procedure is just and reaching the goal of the dialogue. Modern discussions on dialogue ethics focus more on procedure and outcome than principles, and dialogue ethics has been one important perspective to apply when deliberating bioethical issues. A contemporary issue is how one should handle information in biobanks containing human genetical content, where the participant material originates from donors in the community and the content might be used for various research studies. One of the leading contributors to this discussion is the Icelandic ethicist Vilhjalmur Árnason. His thorough work on public deliberation and the Icelandic context of biobank creation constitutes a major part of his academic work. He has from various angles tried to find a fair procedure of dialogue for public deliberation and has also sought the underlying necessary conditions for such a dialogical procedure to be fruitful (Vilhjálmur, 1994; 2000; 2005; 2012; 2015; Vilhjálmur & Gardar, 2004). This has been one of his most important contributions to the ongoing ethical debate, which I will discuss in this paper and critically evaluate. I will not stop there, however.

 

Why did I return to the roots of ethics in the beginning of this paper? Sometimes, one can get new insights by reconsidering old times and old discussions. Vilhjálmur (1991; 2009) also has produced a strand of research within literary studies on Icelandic sagas, which touches upon issues of virtues and core values in old Icelandic society. However, he has not fully combined his work on the ethical foundations of the Icelandic sagas with his thorough studies on public deliberation in modern Icelandic society. The time is ripe for such an analysis, and this is the second intention of my paper.

 

And, finally, how widely can these implications be applied? Are they only applicable to Icelandic conditions or the modern Western sciences as he cautiously proposes in one of his papers (Vilhjálmur & Gardar, 2004)? Or are they applicable interculturally in an inclusive dialogue with regard to cultural differences? This latter question is part of an ongoing discussion in the field of One Health approaches (Mumford et al., 2023), which are global, inter- or transdisciplinary approaches that promote health for humans, animals, plants, and ecosystems in issues shared by these groups (Lerner & Berg, 2017; WHO, 2024).

 

The aim of this paper is to compare two strands of Vilhjalmur Árnason’s ethical work that have been rarely compared, namely his interest in the value foundation in Icelandic sagas and his analysis of dialogue ethics within medical ethics. Each of these strands will be analyzed and then compared to see if there arises a common foundation for the procedure of a dialogue in public deliberation that could be fruitful, both in itself and for other current pressing issues. Finally, I will compare this with recent parallel discussions on indigenous peoples’ claims on a fair dialogue. The result of this comparison might give insights that influence policy formation within One Health approaches.

 

Value foundation in Icelandic sagas

In Vilhjálmur’s studies of Icelandic sagas, he contrasts the romantic reading, which emphasizes the ethical quality of the individual, with the humanist reading, which focuses on moral ideas within the text. Although valuable, both versions tend to miss important perspectives. He aims to find a third, more holistic reading (Vilhjálmur, 1991; 2009). The third version is a sociological reading that situates ethical decisions in a social context in order to understand why people behave as they do. The social order or culture – in this case families, social organizations and the Icelandic Free State (Vilhjálmur, 1991) – contains inherent aspects that set the framework for how ethical dilemmas could be solved, placing an emphasis on relations, constellations or structures. This reading also distinguishes between individual and social honor. If the social dimension is omitted, one might truly misinterpret the concept of honor. As Vilhjálmur writes, “[h]onour has both personal and social dimensions and must not be reduced to either” (Vilhjálmur, 2009: 226). In the third version, there is a balance or tension between personal honor and social honor in society, which simplified can be explained as a tension between personal revenge and societal peace.

 

Each of these three readings has limitations but Vilhjálmur concludes that a political reading, combining the individual and the social, is necessary. He claims:

“The virtues [in the sagas] are necessary in moral life but the precondition for this is a political structure which reduces the effect of personal virtues and vices upon the handling of social affairs.” (Vilhjálmur, 2009: 237)

 

Ethical decisions must be understood at both individual and societal levels, and culture influences both of them. This implies that each culture must be understood on its own terms. The generalizable aspect for all dialogues is the need to consider both individual and societal aspects and the fact that each dialogue exists in a particular cultural setting.

Bioethics

In bioethics, Vilhjálmur has contributed to understanding how a good dialogue should be constituted in three areas. These are the dialogue between a patient and a professional (at the individual level), in public deliberation (at a societal level), and between sciences in interdisciplinary research. In this section, each area will be analyzed consecutively.

 

Between individuals

In patient-professional relations, where the dialogue typically takes place between two individuals on an individual level, Vilhjálmur finds that dialogue is the best approach for helping a patient to make an autonomous decision on treatment options:

“Communication in health care has two main objectives, to inform the patient (and professional) and to provide the patient with emotional support […] A necessary precondition for [rejecting or accepting the options] is that the patient be truthfully and sufficiently informed. […] Informed consent requires conversations because the equalities and inequalities of the partners in the dialogue complement one another.” (Vilhjálmur, 1994: 236-237, original emphasis)

 

He clarifies this by stating that the roles of the physician and patient are different, and that there is a risk that a true dialogue will be absent due to the inequality in the situation. The physician could easily use his/her advantage of knowledge of how the healthcare system works as well as what is known about the disease to steer the dialogue. To avoid paternalism, both individuals need to be aware of the inequalities present and the aspects that can distort the dialogue (Vilhjálmur, 2000). This is why the information needs to be truthfully and sufficiently communicated (Vilhjálmur, 1994). One aspect where the physician has less knowledge is in understanding how the patient experiences his/her life condition. This is one of the patient’s key roles in the dialogue. Therefore, a way to balance the dialogue is to be aware of the different roles in the dialogue. The physician’s role is to understand the disease and communicate treatment options, while the patient’s role is to recognize their own needs and communicate them.

 

Vilhjálmur (1994: 239-240) sees three aspects as important for an authentic dialogue, 1) one needs “a sense for the situation”, 2) one must follow “general ethical principles and values”, and 3) one needs to evaluate the situation with concrete persons in real life conditions, rather than hypothetically. The first aspect, to have a sense for the situation, implies that one needs to clarify what is at stake and try to grasp all the nuances of the issue. The second aspect, to follow general ethical principles and values, implies bringing ethical content into the dialogue in order to gain a deeper understanding of the issue. However, these principles and values need to be dependent on and relevant to the situation at hand. The third aspect, to work with concrete persons in real-life conditions, is a position similar to the one of Seyla Benhabib (1992), who claims that the problem with anonymous others is that actual differences matter in the decision process. Therefore, Vilhjálmur holds a position closer to Benhabib than to Karl-Otto Apel and Jürgen Habermas.

 

Although the ethical content – general ethical principles and values – may seem fixed, the procedure seems to be less rigid. In fact, all three aspects include particularity and contribute to making each ethical dialogue unique. Vilhjálmur claims that each dialogue takes its own path:

“The ‘magic’ of a good authentic conversation is precisely that we do not control it as individuals but are caught up in it and give in to its own movement, which is governed by the subject matter.” (Vilhjálmur, 1994: 237)

 

This implies the challenge of determining the rules for the dialogue’s procedure. A good procedure for the dialogue must allow changes due to the particularity that stems from the state of art in that dialogue. This is mainly due to the actual sense for the situation and the concrete persons involved, each with their real-life conditions.

 

Public deliberation

In his paper on Scientific citizenship in a democratic society (Vilhjálmur, 2012), knowledge from social science is used to enrich the discussion of philosophical bioethics. In his critique on other researchers’ positions, there are a couple of aspects that might be crucial for dialogue ethics. He claims that “the focus needs to be more on the quality of the institutions and governance as conditions for democratic legitimacy than on active participation or pervasive public engagement” (Vilhjálmur, 2012: 928). Public accountability is therefore more important than public participation:

“It is hoped that when citizens authentically engage in conversations about matters of common concern, they are likely to adopt a public standpoint, to broaden their perspective, and be willing to revise their individual preferences in the light of information and arguments.” (Vilhjálmur, 2012: 931)

 

In a paper from 2012, he identifies three aspects to consider when framing a public debate with the aim of facilitating policy work. Firstly, one cannot initiate a dialogue without considering how the issues will be framed. This aspect has received little attention in dialogue ethics, yet it deals with inherent values that might steer the dialogue and therefore needs to be brought forward early to avoid bias. Thereby the aim is to facilitate a fair discussion. Secondly, one must choose where to perform the dialogue by considering which forums and public spaces are appropriate. Thirdly, there must also be a decision on what influence the public deliberation should have on any subsequent decision. One must ask what kind of mandate the public deliberation should have in the issue. All these three aspects are crucial for ensuring a good dialogue.

 

A fourth aspect emerged in an earlier paper. In his study on the Icelandic Health Sector Database, Vilhjálmur (2004) found that time is an important factor. If public deliberation is hastened and constrained by a short timeframe, critical argumentation tends to disappear. Therefore, a proper dialogue requires sufficient time. In summary, this will give us four aspects to consider when preparing a dialogue:

1. How issues are to be framed (what Vilhjálmur calls the pre-framing aspect)
2. What forums and public spaces are appropriate (what I call the arena aspect)
3. What influence the public deliberation has on the policy (what I call the mandate aspect)
4. How much time is needed for sufficient deliberation (what Vilhjálmur calls the time aspect)

 

Interdisciplinary research

In interdisciplinary bioethics, Vilhjálmur (2005) favors the Complementarity thesis, which asserts that moral philosophy, sociology, and legal theory all involve critical argumentation and conceptual analysis. When they work complimentary, they will enrich one another and make the discourse more fruitful. Moral philosophy and analysis, by analogy, have a similar role in interdisciplinary research as empirical sciences have in the healthcare sector:

“Just as empirical science must critically examine truth claims, so ethics needs to critically scrutinize claims to rightness that are embodied in law and local standards, in actual ethical views or an established social consensus.” (Vilhjálmur, 2005: 325)

 

Ethics will, therefore, focus on claims of rightness, whether they are found in legislation, policies, social consensus, or ethical procedures or principles that structure human healthcare:

“A key factor in a successful moral analysis of a particular practice is an attempt to analyze the foundations of the factually accepted. The question is not only what is in fact accepted but also why it is accepted and whether it is worthy of recognition?” (Vilhjálmur, 2005: 325, original emphasis)

 

This could help in understanding the process and pre-requisites of the dialogue. In this paper, he also stresses the difference between people’s acceptance of a moral view and good moral reasoning, claiming that “reflective distancing is the precondition for a fruitful moral investigation” (Vilhjálmur, 2005: 325).

 

In a later paper, Vilhjálmur (2015) returns to the subject from a different perspective. He notes that the social and the existential dimensions are often neglected in bioethics. The social dimension should here be understood as social practices or institutions. The existential dimension entails asking oneself what a good human life or healthcare is. Reflexivity, once again, is central (Vilhjálmur, 2015), integrating the social and existential dimensions, similar to his earlier findings in the study of Icelandic sagas.

Summary of Vilhjálmur

Combining Vilhjálmur’s literary analysis on Icelandic sagas with his work in bioethics results in the following points, which will facilitate future discussions of ethics among citizens in multicultural communities:

• Cultures or sciences contributing must be understood on their own terms
• Sufficient levels must be considered, both individual and societal aspects matter
• An openness to the variability of dialogues depending on the subject matter and the concrete persons
• A proper pre-framing of the dialogue
• A sufficient choice of arena
• A justification of the mandate aspect
• Sufficient time for the dialogue
• Reflexivity must encompass also social and existential dimensions

 

The first two points originate from the study of the sagas and the others originate from the study of bioethics. The second point also relates to the idea of having a sense for the situation or context. If we tentatively agree that these points formulated here will be consistent with Icelandic conditions, can they be applied to another setting? I will now try to adapt these findings on interdisciplinary, holistic approaches to health promotion, such as One Health, with which I have previously worked (Lerner & Berg, 2017; Lerner & Zinsstag, 2021). I will specifically focus on claims of fair dialogue from non-Western communities. In the next section, I will briefly present One Health approaches and then present the claims on a fair dialogue with specific emphasis on Indigenous peoples’ claims. Finally, I will apply the points mentioned above to see the result.

One Health approaches and Indigenous peoples claims on a fair dialogue

Many problems we are facing at the moment, such as poverty, pandemics, resource depletion, and climate change, do not only affect humans. It is increasingly clear that humans, animals, plants, and the environment are intertwined and that a solution to one problem often needs consideration of all involved. In science, within the public health sector, several new approaches have emerged since 2004, trying to solve these problems with an inter- or transdisciplinary perspective. Thereby the aim is to simultaneously promote the health of humans, animal, plants, and ecosystems. These are called One Health approaches (Lerner & Zinsstag, 2021). Ethical issues might be particularly challenging, since in their widest demarcation one needs to combine anthropocentric, zoocentric, biocentric, and ecocentric viewpoints.

 

One Health approaches

The main One Health approaches are One Health, EcoHealth and Planetary Health. All emphasize the inextricable connection of health in humans, animals, plants, and ecosystems. They are inter- or transdisciplinary and address multispecies health issues such as zoonoses, harmful environments etc. Compared to the Icelandic biobank case, in One Health approaches, one also needs to consider ethical issues with keeping the genomes of animals and plants. Biopiracy is a further important issue of discussion. One Health originated from a veterinarian-human medicine perspective, Ecohealth from an ecological perspective, and Planetary Health from a public health perspective (Lerner & Berg, 2017). Today they might be regarded as similar, but there are still differences in their underlying values due to their different origins. Similar to Vilhjálmur, One Health approaches are to an increasing extent recognizing social aspects as crucial to a solution. (Scoones & Forster, 2009).

 

Ethics, which has been fundamental in public health, has been rather shallow or absent within One Health approaches. The application of dialogue ethics within One Health approaches has been mentioned, though an elaborated version is still lacking. In their work on core competencies for persons working with One Health approaches, Laing et al. (2023) recognize effective communication as one of these competencies. In order to have effective communication one needs a dialogical form that can bring “social, relational and cultural contexts into their dialogue and co-generate and negotiate meaning” (Laing et al., 2023: 6). An inclusive variety is needed to cover all aspects of the health issue considered, which is an important part of holistic One Health approaches. Therefore, the dialogue must bridge different knowledge and value systems while the participants are aware of risks due to power relations and barriers.

 

Based on the Planetary Health approach, Foster et al. (2020) have tried to outline an ethical framework where dialogue ethics might be a part of ethics within One Health approaches. They argue that the best way to present risks is in the form of a dialogue. All affected parties need to know the risks of the interventions. Foster et al. present several aspects that facilitate this process, which can be summarized as follows:

1. Information must be presented honestly and objectively
2. The duty to communicate risk is a duty both to listen attentively and to communicate through the language and worldview of the affected people
3. A right to know is also a right to hope (Foster et al., 2020: 465-466).

 

However, this quote, along with the rest of their elaboration on the topic, presents a monologue rather than a dialogue, where the main goal is the transfer of information from an informing entity to an affected party (Foster et al., 2020: 464). A dialogue needs to have at least two parties with as equal standing as possible in order to be a dialogue. The problem with the description in Foster et al. is that the dialogue is one-sided; the Planetary Health educated people give the information and shape how those included should respond. In such cases there is an obvious risk for lack of equal respect (one side has already decided which information is deemed important). Vilhjálmur’s claims – that the dialogue should be able to take its own path, with reflexivity present in both parties through a reciprocal awareness of one another’s roles – offers a more sufficient solution than the one Foster et al. proposes. In their view on dialogue, they present it as a simple presentation and a response. But this setup implies an obvious power relation that hinders those informed from reversing the perspectives as well as being able to disagree. However, being able to reverse the perspectives and being able to disagree could further the process into more dialogue with the result of a deeper understanding of the complex problem.

 

One Health approaches thus need to align more closely with de Paula’s (2021) suggestions for trustworthy interpersonal communication in Planetary Health:

However, to navigate complex systems, as Planetary Health requires, specific characteristics must be accentuated. These include curiosity, humility, acceptance of uncertainty, reflexivity (being conscious of one’s own role, prejudices and power), and being open to different ways of seeing the world. (de Paula, 2021: 84)

 

This is in line with Vilhjálmur’s views. Both de Paula and Laing et al. emphasize the need for wider inclusion. Within the three One Health approaches mentioned, there has been calls for wider inclusion so as to include views beyond Western scientific knowledge and value systems. Today, proposals within One Health (Mumford et al., 2023), EcoHealth (Saint-Charles et al., 2014), and Planetary Health (Redvers et al., 2020) ask for Indigenous peoples’ values and knowledge to be acknowledged in policy making. I will now turn to these suggestions.

 

Indigenous peoples’ claims

Indigenous peoples’ ethics and values have received limited attention compared to Western scientific ethics. However, differences in procedures and values between Western scientific ethics and Indigenous peoples’ ethics have been studied with regard to policy making, especially with the aim of finding policies and procedures that include the views of both sides reciprocally and fairly. One promising area of study is the analysis of ethical codes, guidelines, and frameworks in the field of research ethics, where reciprocity is needed in order to avoid unethical treatment of those included in research. Herman (2014), Tunón et al. (2016), and Brant et al. (2023) have in their different studies analyzed well above 40 documents with only minor overlap. Despite different results, three areas of concern in ethics are evident in all three studies. These are:

• Respect for Indigenous worldviews, values and rights
• Responsibility as a scholar
• Reciprocity and relational accountability

 

The first area, respect, involves recognizing Indigenous rights, aligning with Indigenous worldviews, engaging in open consultation, and a just and equitable process. Worth remembering is that Indigenous peoples' worldviews are holistic, and religious and ethical values are often intertwined.

 

The second area, responsibility, sets focus on the domain of the researcher. The researcher needs to follow the guiding rules for research ethics. Aspects of confidentiality and consent are central but there are also other related issues, such as protection of knowledge so that Indigenous peoples avoid suffering from for example biopiracy.

 

The third area, reciprocity, involves aspects such as partnership, mutual benefits, and relational accountability. These aspects are far-reaching and might as in the Akwé: Kon guidelines (Secretariat of the Convention on Biological Diversity, 2004) involve all aspects of preparatory work, planning, development, and implementation of a project. This implies that Indigenous peoples also must be included in the pre-framing phase of a dialogue. Together with responsibility and respect these three areas can safeguard Indigenous peoples’ livelihoods, culture and future.

Comparison between Indigenous peoples’ claims and Vilhjálmur’s claims for a just dialogue

How do One Health approaches and Indigenous Peoples’ claims align with Vilhjálmur’s findings in Icelandic sagas and bioethics?

 

The claim that the Indigenous peoples’ culture and values must be involved, acknowledged, and understood is in line with Vilhjálmur’s Cultures or sciences contributing must be understood on their own terms, especially if Indigenous peoples become part of the pre-framing of the dialogue. This meets the claims of respect from Indigenous peoples. The pre-framing part of the dialogue is then able to choose a sufficient choice of arena as well as to determine how to justify the mandate. The last aspect also connects to the claim of responsibility from Indigenous peoples. To justify the mandate might for example include safeguarding the rights to specific knowledge (which often is collective) held by Indigenous peoples to avoid biopiracy, so that others cannot patent it and make earnings without giving the Indigenous peoples their fair share (e.g., Mackey & Liang, 2012).

 

In order to reach the claim by Vilhjálmur for sufficient time one has to consider that time might differ between cultural settings and several forms of cultural time exist (see Helman, 2007: 33-35). This potential difference needs to be considered within the dialogical framework. Regarding the aspect of sufficient levels to be considered one has to remember that there is a difference between individual and collective cultures, thus there must be several levels allowed in the dialogue. This will also influence social and existential dimensions, which must be included in the reflexivity process.

 

If the aspects above are allowed to be decided solely by the subject of the issue itself together with those who participate, and not by a preconceived structural form, one will fulfil Vilhjálmur’s idea that the dialogue will follow its own path due to the openness to the variability of dialogues depending on the subject matter. Also, all these criteria are in line with the claim of reciprocity from Indigenous peoples.

 

Conclusion

I have in this paper tried to demonstrate how Vilhjálmur Árnason’s studies of the values within Icelandic sagas can be combined with his studies on ethical dialogue in order to provide a list of criteria that could be useful when deciding on a fair dialogical procedure. I have compared this list of criteria to a rather shallow debate on dialogue within One Health approaches and then applied the list to claims from Indigenous peoples for a proper research ethic. I have found that this seems to be a fruitful way forward for One Health approaches, with the aim of strengthening their ethical discussion and achieving inclusion of marginalized groups.

Notes

¹ In Iceland, the surname – Árnason – is a patronymic and a description rather than a name. Icelanders use and are known by their given name. This practice is followed throughout this article and Vilhjálmur Árnason will be referred to as Vilhjálmur when citing his works.

References