Etikk i praksis. Nordic Journal of Applied Ethics (2024), 18(2), 61-72 |
http://dx.doi.org/10.5324/eip.v18i2.6280 |
First publication date: 27
December 2024 |
Context-sensitive
Dialogues: Response and Reflections
Vilhjálmur Árnason
University of Iceland, School
of Humanities, vilhjarn@hi.is
This article reflects on the central themes of Vilhjálmur Árnason's work, particularly his focus on contextualized morality and dialogical ethics. Vilhjálmur emphasizes the importance of balancing individual freedom and responsibility with an understanding of social and political contexts. By examining relational ethics across healthcare, research, and public health, the article highlights his contributions to bioethics, including concepts like informed consent, scientific citizenship, and authorization in biobank research. Vilhjálmur1 advocates for communicative reasoning and authentic dialogue as essential tools for ethical analysis, situational decision-making, and fostering trust in research and healthcare practices. The work underscores the importance of trustworthiness, veracity, and participatory engagement in addressing modern ethical challenges, particularly in rapidly advancing biotechnologies. Keywords: Contextual ethics, dialogical ethics, relational autonomy, informed consent, authorization, bioethics, trustworthiness, communicative reasoning, healthcare ethics, public health ethics, scientific citizenship, biobank research
I am most grateful to my colleagues for reflecting on my work and providing me with this opportunity to respond to their thoughtful reflections. I will both try to clarify the ideas that they focus on and place them in the larger context of my research.
A major theme in the articles
in this special section is my approach to
morality and moral issues. This is something
I have been grappling with since my very
first encounter with moral philosophy. While
I was fascinated by the ideas of
existentialism and their moral implications,
I missed recognition of how individuals are
embedded in the social context which both
facilitates and restricts our options. I
found helpful analyses of this in
philosophical hermeneutics and critical
theory which I drew upon in my doctoral work
(Vilhjálmur 1982). The notion of
context played a key role in my attempt to
reconcile the existential emphasis on
individual freedom and responsibility with
the hermeneutical awareness of the role that
sedimented meanings and various power
relations play in our lives. I tried to
flesh this out in my first post-doctoral
research project on morality and social
structure in the Icelandic sagas. As
mentioned by both Henrik Lerner and Margit
Sutrop, my writings on the Icelandic sagas
exemplify the importance of the
socio-political context of an
ethical-hermeneutical analysis while warning
against a sociological reduction of
morality. My aim was to find the appropriate
balance between the individual qualities of
the saga characters and the socio-political
institutions in interpretations of saga
morality (Vilhjálmur 1991; Vilhjálmur 2009a).
In my reflections on the sagas,
I am primarily making a hermeneutical point.
The thrust of my argument is that the
dynamics of saga morality, and the voices of
their characters, are not understood without
seeing them against the background of the
free state. The lack of political
institutions provided the background for the
saga ethos, characterized by a tension
between unconditional claims for honor
related to the duty of vengeance and the
social need for peace. Prevailing
interpretations of the saga morality had
lost sight of this and overemphasized the
role of both individual character traits
and/or religious ideas. I argued that the
task is to account for the social structures
which channel individual actions without
reducing them to structural accounts that
leave no room for normative evaluation.
These reflections raise
two important questions for all
ethical analyses. The first relates to
understanding and the second to
normativity, and the two issues are
interrelated. In the case of
bioethics, this has served as a
reminder for paying attention to the
social-political context of ethical
analysis and reasoning. Ignoring
that implies not only a risk of
leaving out things that are important
for understanding moral issues, but
also of inadvertently assuming a
legitimating and ideological role in
the discussion about new biotechnology
or policies. Narrow bioethical
analysis in this sense is subject to
the risk of the ethicist inadvertently
going in the service of powers that
are not in the public interest
(Vilhjálmur 2011a). I have
demonstrated the limits of
technological instrumentality in this
regard and argued for the importance
of communicative reasoning for a
critical appraisal of the preferences
that fuel biotechnological policies
(Vilhjálmur 2015).
This is also of major relevance
for the other question or challenge raised
by my emphasis on the social context: How
can this contextualization of morality
account for normativity? In the case of the
sagas, there are both thick normative
notions of honor and high-mindedness and
more procedural ideas relating to the need
for peace and conflict resolution in a
stateless society. In a post-metaphysical
world, procedural ideas, and their personal
and institutional conditions, are crucial.
For this, forms of communicative rationality
are also of major relevance. As clearly
described by Svava Sigurðardóttir (2024),
the vehicle for this in my writings has been
the conversation or dialogue, both as a way
of critical reasoning and as a mode of
caring interaction. Henrik Lerner also
points out that the notion of dialogue and
the notion of context are the two key ideas
in my writings. As a way of reasoning, the
dialogue has a critical force, built into
the free exchange of arguments (Vilhjálmur,
2005a). However, this part of discourse
ethics has not been central in my writings.
I have always emphasized the need for
contextualized reasoning rather than the
decontextualized approach that has prevailed
in discourse ethics (Vilhjálmur, 2000b). Lerner rightly observes that my
dialogical ethics is more akin to Seyla
Benhabib’s version of discourse ethics
(Benhabib 1992) than those of Apel and
Habermas. I have also been impressed by
Simone Chambers’s emphasis on accountability
rather than consent as a key notion of
practical discourse (Chambers 2003). Both
these authors bring discourse ethics into
real context and do not make the sharp
distinction between justification and
application as Habermas does. Recognizing
this, Lerner discusses my importance of
“openness to the variability of dialogues”
(Lerner, 2024). I have emphasized that both
the way of reasoning and analyses of the
mode of interaction must be sensitive to the
fact that they take place in different
relational contexts. In bioethics there are
three major relational contexts which have
different implications for the conduct of
dialogue, both as a way of reasoning and as
a mode of interaction. These are the
relational contexts of patient-professional
interaction, the participant-researcher
interaction, and the citizen-policy maker
interaction. As Svava (2024) demonstrates in
her article, these are in focus of my book,
Ethics of Life and Death (Vilhjálmur
2023b; Vilhjálmur 2005b). The
subtitle of the book, Healthcare, research
and public health, refers to these three
relational contexts. When the dialogue is
appropriately carried out – I have used the
notion of authentic dialogue for this
(Vilhjálmur 1994) – it exemplifies moral
respect for those involved. This respect for
human beings is concretely fleshed out in
the different relational contexts as respect
for the individual patient, for the research
participant and for the citizen in the case
of health policy. The first of these is the
clearest example of a personal encounter, an
I-Thou relation as analyzed by Buber and
Gadamer (Vilhjálmur 2000a). In many cases,
this also applies in clinical research where
the researcher and the research participant
can have an exchange. Such an exchange is
conducive to informed consent for
participation in research which has been
aptly described as a “process of
communication” (Grady 2015).
As Bjørn Hofmann discusses in
his article, I proposed the notion of
‘authorization’ for conditions of the use of
and access to the data and samples donated
in the database complex. One reason for
introducing the term ‘authorization’ was to
break new ground in the discourse about
consent for database research. The notion of
informed consent was used in confusing ways
and was often mixed up with explicit consent
instead of presumed consent. In order to
deal with this new situation, a complex
cluster of consent types – “new conceptions
of consent”, as Hofmann (2024) puts it – was
introduced. I thought that a new word might
help to clarify the issue, not least the
widespread popular misconception that
consent for participation in database
research counted as informed consent. As
Hofmann rightly observes, this was not only
a matter of coining a new concept but an
effort to describe more truthfully what
participation in database research implies.
Hofmann is right, however, that
I have not always been clear about the
difference between authorization and
consent, and his elaboration of conditioned
authorization advances the discussion more
than I have done in my writings. Hofmann
discusses several challenges for
authorization raised by the new research and
clinical possibilities. These are complex
issues, and I will not try to elaborate on
them here. I mainly want to stress that
there is a need to focus even more on the
responsibility and accountability of
researchers and regulators than on the
understanding, competency and voluntariness
of participants. It is of major importance
to increase and improve the obligations of
researchers and regulators in the aim of
strengthening their trustworthiness. Most
research participants are vulnerable in the
sense that they lack the ability “to
understand (and control) the (future) use of
biological material and health information”
(Hofmann 2024). This general vulnerability
requires that we focus on how good reasons
the participants have for trusting
researchers and regulators to handle their
material in a responsible way, i.e. in line
both with what they have authorized and with
good research practices. This calls for
increased transparency and clarification of
research practices and their regulation or,
as Hofmann (2024) puts it, this enhances the
need to “specify the accountability
requirements” in authorizations. Avoiding misleading conceptions
of consent is a part of attempts to underpin
trustworthiness of research practices.
Veracity is an important but widely
neglected moral demand in population genetic
research where hype of benefits is common.
Participants need to be able to trust that
risks and benefits are truthfully explained
and that their participation in research
contributes to the common good. This is one
reason why I have, as Svava points out,
increasingly emphasized the moral aim of
protecting participants against
manipulation, deception (hype is a form of
that), and coercion.2
This is an unconditional duty in research
ethics, while provision of information is a
matter of contextual judgment. This is
relevant for the question of how the rapid
development of new research possibilities,
such as those related to PeRBEs discussed by
Hofmann, affects the practice of
authorization for participation in database
and biobank research. These technological
and scientific advances will generate
research possibilities and clinical options
which could be tempting to specify in the
authorization. In addition to the lack of
explainability, the danger is that such
specifications would overwhelm and confuse
the participants. As Hofmann (2024)
describes (drawing on Wiertz and Boldt
2022), developments of better scientific
practice, more trustworthiness of
institutions, and increased safety of data
reduce the need for such specification. But
this does not imply that the need for the
specifications of the “five key issues”,
described by Hofmann’s conditioned
authorization, are in any way reduced
(Hofmann 2024). To the contrary: New
research possibilities increase the need to
address possible consequences for risks and
benefits and to openly recognize the
uncertainty of both. Again, the veracity
requirement is crucial here and honest
admission of ignorance about clinical
benefits, for example, is part of that. In my formulation of the idea
of authorization, there was an emphasis on
trustworthy regulatory institutions and
research practitioners. It is primarily
their task to ensure that what is done to
the material donated is in line with what
the participants have authorized. This
emphasis on trust has increased with the
rapid development of new research
possibilities and access to information.
Contrary to those who have argued that these
possibilities create conditions for
empowering citizens (Brand & Brand 2011;
for a critical discussion, see Juengst et
al., 2012), I see them as reasons for being
concerned about increased vulnerability of
population research participants. This
situation requires that we create conditions
for entrustment. According to the Oxford
English Dictionary, to entrust is “to assign
the responsibility for something valued to
(a person, organization, etc.)”.3
In this context, authorization implies
entrustment in the sense that it assigns the
responsibility for overseeing the handling
of the material to researchers and
regulators. The material is put in their
care in the trust that in their evaluation
of new research possibilities they will
abide by good research practices and honor
the general conditions for use and access
given in the authorizations. It needs to be asked how this
emphasis on entrustment squares with the
ideas of scientific citizenship where the
emphasis is on the participants’ agency. As
Hofmann points out, these ideas of
scientific citizenship were developed in the
process of my reflections on how to
implement authorization for database
research. Instead of focusing on the nature
of the initial consent, narrow or wide,
participants should have the possibility to
follow the course of research and reevaluate
their authorization. In an ever-changing
research environment, where new
possibilities for the use of the material
constantly arise, it is an important
condition that research participants are
enabled to follow the research practices. To
see the connection with scientific
citizenship, the entrustment idea must be
connected to this dynamic aspect of
authorization. This implies that
participants would be enabled to follow
their participation in scientific research
and reflect on it. Participants could thus
be aware of what is done with their
material, they could reevaluate their
participation and withdraw from research if
the practices are not in line with what they
have authorized. Possibilities for
withdrawal are, however, dependent on
context and may be restricted for various
reasons. My argument for scientific
citizenship was also advanced as
complementary to the prevailing emphasis in
research on participants’ protection and
benefits which both envision the
participants in a passive role (Vilhjálmur
2009b). I
argued that the notion of benefit had been
understood in far too narrow terms of
utility and that a major public interest
resides in increasing the scientific
awareness and literacy of the citizens
(Vilhjálmur 2011b). In the context of
population database and biobank research,
this can be done by creating conditions for
participants to follow their participation
in scientific research and reflect on it. It
is an integral part of this that the
participant can be informed about the
development of the research practices and
the corresponding regulatory policies. In
conjunction with the option of withdrawal
from research, this should have the effect
of enhancing the trustworthiness of research
practices and their regulation. To underpin
this further, regulators and researchers
should be obliged to account for their
decisions regarding research material and
take the initiative to communicate with
participants so that they can stay informed
and vigilant. In this way, the authorization
becomes dynamic and facilitates civic
awareness and scientific literacy. This description of the
conditions for dialogue between research
participants and research regulators and
practitioners resonates with the focus on
accountability in my writings on scientific
citizenship in the spirit of deliberative
democratic theory (Vilhjálmur 2013). In my
reflections on this issue, I gradually
shifted emphasis from the benefit involved
in public engagement to a focus on practices
of accountability and justification as
conditions for trustworthiness. Again, this
points to the responsibility of research
practitioners and regulators instead of
placing the burden on the participants. In
addition to the vulnerability of
participants caused by the complexity of the
rapidly evolving research practices, the
citizens generally are in the grips of
forces which are shaping them. This has been
more analyzed by sociological theorists of
biopolitics than bioethicists (Rose &
Novas, 2004). Their analysis has shown, for
instance, the danger of misusing
deliberative exercises, for example by
narrow framing of the subject matter,
focusing on down-stream rather than upstream
issues (Irwin, 2001). This is particularly
risky when it comes to new biotechnologies
which people have little or no experience
of. In those cases, monological critical
bioethical analyses are crucial
contributions to public debates. While I find it necessary to
recognize the molding socio-political forces
and take them into account in ethical
discussion, I have been critical of the
sociological analysis of biological
citizenship which focuses exclusively on
“the constitution of the subjects as
vehicles of biopower” (Vilhjálmur 2013:
938). I
have emphasized the need to keep alive a
vision of the scientific citizenry which
provides democratic resistance to this
formation. As in my analyses of the
Icelandic sagas, the point is to account for
the molding forces of the socio-political
context, without reducing the normative
dimension to structural relations. I try to
reconcile the normative dimension of
bioethical discourse with radical
situatedness of the subject or the citizen
in socio-political context. I have argued
that this important biopolitical perspective
needs to be complemented by a normative
conception in the spirit of discourse
democratic theory (Vilhjálmur 2017b). This democratic vision has
increasingly characterized my research which
in recent decades has been largely related
to two events and activities in Iceland
which have raised important questions in
applied ethics and socio-political
philosophy. I have already mentioned the
construction of a population database as a
resource for genetic research, and later the
subsequent use of genetic information in
research and health care came into focus.
But I was also involved in the investigation
of the causes and aftermath of the financial
collapse and how that was facilitated by
weak professional and democratic practices
(Vilhjálmur 2010).4
The analysis of processes which transform
citizens “into a potential resource for the
generation of wealth and health” (Rose &
Novas 2004: 456) is instructive for both
these lines of research. The discourse of
biopolitics thus provided a good opportunity
for me to bring together these two different
lines of my research. Margit Sutrop thus rightly
emphasizes that my writings demonstrate that
“a holistic understanding of
morality must incorporate broader social and
political dimensions” (Sutrop 2024). Her
main example is my paper “The Personal is
Political” where I argue that the four
principles of biomedical ethics are
insufficient for the task to evaluate the
ethical and social implications of
personalized medicine (Vilhjálmur, 2012).
However, as should be clear from many of my
writings, I am not as critical of
principlism as Sutrop’s article seems to
imply. I have emphasized that each of the
four principles are aimed at protecting
basic moral interests which people are
likely to claim for themselves and teach
their children. This invites an appeal to
common morality in the sense that the
principles must be anchored in the ethical
self-understanding of people and the social
ethos which provides a normative background
for their interaction. My
criticism of principlism is therefore not
aimed at its substantive aspect, but rather at a
narrow understanding of the principles and
their thoughtless application: The “problem” with the four
Georgetown principles is therefore not which
principles are put forth but rather how they
are often thoughtlessly applied and
simplistically identified with certain types
of North American interpretation of the
underlying values. Moral principles are not
fixed rules but general guides for moral
reflection which indicate which values are
generally of importance for free human
beings (Vilhjálmur 2006: 386). In my
employment of the principles, I have
therefore made an effort to interpret them
in relation to the socio-political fabric
which sustains the interests that they are
intended to protect. Contrary to ‘a
checklist approach’, I have regarded the
principles as an invitation for further
moral thinking and interpretation. This I
find fully compatible with the presentation
of Beauchamp and Childress (2019: 442) of
the goal “to identify the relevant
particular moral judgments, rules, concepts,
data, and theories as resources for moral
reflection and to bring them into
equilibrium … in which all beliefs fit
together coherently”. I have
also been critical of the monological
approach characteristic of principlism.
Beauchamp and Childress (2019: 13) create “an analytical framework of
general norms derived from the common
morality” but disregard how these norms are
handled by the actors themselves in the
different relational contexts which I
described above. This is a major reason for
adopting a dialogical approach in bioethics.
This does not imply that dialogical
reasoning is to replace other modes of
bioethical argumentation but to complement
them, especially in the relational domains
(Vilhjálmur, 2024). Moreover, I have never
hesitated to draw upon different ethical
theories to advance my arguments and, as
Svava shows, my idea of a contextually
sensitive dialogue is sustained both by
Kantian and Aristotelian arguments. Considering this, my answer to
the question posed by Margit Sutrop (2024): “what kind of
ethical theory does bioethics truly
require?” is therefore not a substantial
value theory, but rather a procedural
theory relating to communicative practices
and their conditions in relational or
interactional contexts. In Svava’s
description of my comprehensive book on
healthcare ethics, she shows well the key
role that context sensitive dialogue plays
in my writings. In fact, Sutrop (2024) puts this succinctly
when she writes that my work in medical
ethics: “underscores dialogue as an
essential tool for resolving ethical
dilemmas and navigating bioethical
complexities”. As such, dialogue is an
optimal method for joint decision-making
where “the process of specification and
balancing of norms” is not just a task of
the ethicists but a common reflection of
those involved or affected. As a rule,
thoughtful dialogue is a good mode of
interaction in healthcare; it can “foster
mutual understanding”, as Sutrop mentions,
not least when there is a “collision of
values” or disagreement of other kinds. In
authentic dialogue, people meet in the
subject matter and are willing to reflect on
their values and biases, and reconsider
their preferences in light of information
and arguments. As Thomas Nagel (1997: 141)
writes, “in most cases a reasonable decision
can be reached only by a sound judgment,
informed as well as possible by the best
arguments that any discipline can have”. It is a key element in
dialogical ethics that in relational
contexts a “reasonable decision” cannot be
made without taking the perspectives of
those affected by the decision into account.
The ethics expert can serve as a midwife in
bringing forth such a decision, but it must
be made in a deliberative process of those
involved. This is a major difference between
communicative and technical rationality.
It is difficult to
say much more in a decontextual way about reasonable decision-making in
the case of conflict. We need to be informed
about the facts of the situation, who are
involved, what rights and duties they have
and other relevant features, as seen from
Svava Sigurðardóttir’s description of my
guidelines for discussing cases. It is of
crucial importance, for example, whether
value disagreement occurs in the
asymmetrical patient-professional
relationship or in public deliberation
between ’free and equal’ citizens. For
example, there are quite different norms in
good medical practice and in good democratic
governance that can bring the conflict to a
resolution. But the resolution need not be
regarded as optimal from any other point of
view than that involved in a “fair
procedure”. However, in dialogical ethics
the procedural cannot and should not be
fully separated from the substantial. These are
different contexts and require different
kinds of dialogical practices, but in all
cases the
focus is on the conditions for communication
in the handling of the moral issues. These
conditions are both personal,
institutional-professional and
socio-political (Vilhjálmur 2000; Vilhjálmur
2024). The personal conditions are
conversational virtues, such as willingness
to enter a dialogue and competence to carry
it out. When individuals take on
professional roles they come with
role-specific obligations which may imply
conversational constraints (Ackerman 1989).
This is, for example, the case in the
patient-professional relationship which has
important implications for the understanding
of patient autonomy (Vilhjálmur & Stefán
2016). Patients should only be faced with
options that are compatible with
professional responsibility, but their right
to refuse all treatment options on the basis
of fundamental disagreement on values is
generally uncontested. It is hard to
translate this into the relational context
of citizen-policy maker in a democratic
society. As Albrecht Wellmer (1996: 134)
writes, “the norms themselves carry, so to
speak, a situation index which binds them to
the situations in which they have their
origin”. A disagreement about contextual
norms in praxis is therefore quite different
from value conflicts in theoretical debates.
I tend to agree with the claim of Beauchamp
and Childress “that distinctions among types
of theory are not as significant for
practical ethics as some seem to think”
(Beauchamp & Childress 2013: 363). All dialogues are enveloped by
institutional and socio-political context
which can either facilitate or hamper
communicative practices. Furthermore,
bioethical policies have social implications
which is the main point of my argument in
the paper “The Personal is Political”. An
assessment of these implications requires
public dialogue and good democratic
practices which can be analyzed in terms of
discourse theory. While such analysis is
important in the relational context of
citizen-policy maker, the
patient-professional relation requires quite
different dialogical practices. A still
deeper analysis may be needed when the very
conditions of our communicative practices
are threatened by instrumentalization of
reproduction (Vilhjálmur 2014; Vilhjálmur
2017a). It is a major task of critical
bioethics to resist the dominant use of
instrumental reasoning in the relational
domains which undermines the conditions for
good communicative practices (Vilhjálmur
2015). It has been well
said that in bioethics “moral reason is
brought to bear on issues in healthcare,
human research, and health policy” (McMillan
2020; Battin 2013). My contention is that in
order to deal with some of the main
challenges to good practices in healthcare,
research and health policy, it is imperative
to strengthen the conditions for
communicative reasoning and dialogical
interaction. It should already be clear that
a dialogical approach does not try to
monologically add to the four principles or
replace them with others. In some cases, it
is important to point out the shortcomings
of interpretations of certain principles, as
I have done in the cases of justice
(solidarity, as Margit points out; also
Vilhjálmur 2009c) and autonomy (dignity,
Vilhjálmur 2021). As we have seen, there are
substantive values and conversational
virtues implied in the notion of authentic
dialogue, and the conditions for
communicative practices have clear normative
elements. Clearly, “monological” conceptual
work is quite compatible with a dialogical
approach.
AcknowledgementsI would like to thank Bjørn Hofmann and Kadri Simm for their initiative and work on this special issue. I am also grateful to the editors of Etikk i praksis for devoting this issue to my work.
Notes1
In Iceland, the
surname – Árnason – is
a patronymic and a
description rather
than a family 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
my works.
References |