Socratic
Dialogue as a New Means of Participatory Technology Assessment?
The
case of Xenotransplantation
Beate
Littig, Institute for Advances Studies, Vienna
1.
Introduction
Xenotransplantation
(in the following XTP), or animal-to-human transplantation involves the
transplantation of animal organs, tissues or cells into humans.[1]
Xenotransplantation,
like many developments in modern medicine, science and technology, bears
enormous chances, but is also associated with new risks (Bonß 1995) and major ethical
problems. Ethical questions of new technologies challenge our existing decision
making mechanism. The questions in this context are not only: Who is going to
decide? And: On which basis are we going to decide? But also: In which way can
we debate these complex issues? Who can legitimately discuss and resolve
ethical problems of science and technology? Is it sufficient to only include
professionals (including bioethics experts) or do we need a broader ethical
debate, which also involves other actors in the field including the concerned
public and /or civil society (c.f. Chadwick 1999). Furthermore, if a broad
public discourse on the ethical problems of modern science and technology is
both necessary and desirable, how can these questions be debated and resolved,
and what decision-making procedures can be used to resolve ethical questions?
This
paper gives a description of an international research project, which
introduces and evaluates a well-established method for resolving ethical issues
- the Neo Socratic Dialogue (in the following NSD) - into debates on
technological risks in modern societies.[2]
The NSD traces back to the Socratic Dialogue, which has been developed by
Leonard Nelson in the 1920s (Nelson 1922,1965). The issue under discussion in
this project are ethical questions of xenotransplantation. The following
sections will give a short overview on these ethical problems and on NSD as a
new means of PTA. Furthermore it will present an outline of the above mentioned
research project.
2.
Ethical Questions of Xenotransplantation
XTP,
like many developments in modern science and technology, is associated with new
risks and raises a number of major ethical problems. Whilst XTP could help
solve the shortage of organs from human donors and save the lives of many
patients waiting for transplantation[3],
there is a serious risk that viruses which cause animal diseases might cross
the species barrier and spread through human populations.
Ethical
questions of XTP still to be resolved include:
• Is it
in principle acceptable for reasons of religious believe, cultural values and
animal welfare to use animals to provide organs and tissues for transplantation
into human beings?
• Which
animals could be used (primates or non-primates)?
• Is it
acceptable to save the life of an individual whilst putting at risk health care
professionals, relatives and the general population?
• Is it
acceptable to restrict the individual freedom of xenograft recipients to
protect public health?
• Is it
acceptable to neglect alternative approaches to solving the donor organ
shortage and to invest limited research resources into a technology, the
success of which is highly insecure?
EU
Member States vary considerably in the public awareness and discussion of XTP.
While some countries have already set up expert commissions to investigate the
problems of XTP and have started to issue related guidelines - e.g. for the UK,
for the Netherlands and for Germany - many other countries have yet to address
XTP.
Apart
from the lack of a well developed public debate on the ethical issues raised by
XTP, a basic and still unresolved problem in many modern societies is: who can
legitimately discuss and resolve ethical problems of science and technology? Is
it sufficient to only include professional bioethicists or do we need a broader
ethical debate, which also involves other actors in the field including the
concerned public.
Furthermore,
if a broad public discourse on the ethical problems of modern science and
technology is both necessary and desirable, how can these questions be debated
and resolved, and what decision-making procedures can legitimately be used to
resolve ethical questions?
3. The
Neo-Socratic Dialogue (NSD)
A NSD
is an inquiry into ideas, originally meant to find consensus on some topic
through a joint deliberation and weighing-up of arguments. The dialogue aims at
visioning, explaining values and clarifying fundamental concepts. It implies a
systematic investigation of our assumptions, reasons and viewpoints, and a
cooperative testing of their validity. In the dialogue participants attempt to
formulate legitimate principles and develop a shared and inspiring perspective
(Nelson 1922, 1965, Heckmann 1993).
A
second aim of the NSD is to learn to have a dialogue instead of a discussion.
This requires adequate command of a number of dialogical roles, skills and
attitudes, especially suspending judgements and keeping a balance between
taking position and resigning. Both aims are intimately connected to the
development of strategy, organisational learning and knowledge management.
The NSD
has been successfully applied so far in medical ethics (Birnbacher 1999),
university teaching (Heckmann 1993, Birnbacher 1982, Kleinknecht 1989,
Gronke/Stary 1998, Littig 1999), organisational learning (Kessels: 1996),
business ethics (Kessels 1997/2001), as well as primary education (Weierstraß
1967, Murris 2000). The proposed research project will introduce this method
into PTA.
A NSD
is focussed on a single fundamental ethical question. A NSD is applied to a
concrete experience of one of the participants that is accessible to all other
participants. Systematic reflection upon this experience is accompanied by a
search for shared judgments and underlying reasons for these. In the case of
xenotransplantation these question can be the following:
• To
which extent does individual benefit justify collective risk?
• Do
animals have rights?
•
Should animals' rights restrict the right of humans to live? To which extent?
• Does
the purpose for which animals are used make a difference (diet,
transplantation)?
• Are
humans allowed to blur the boundaries between the species?
• Are
measures, which could become necessary to protect public health in accordance
with human rights?
What is
basically Socratic in the NSD is the method of rigorous inquiry into the
thoughts, concepts and values we hold as true. The NSD is a joint investigation
into the assumptions we make when we formulate our thoughts.
The NSD
follows the following procedure:
•
Before the discourse commences a well formulated, general question is devised.
• The
first step is to collect concrete examples experienced by participants in which
the given question plays a key role.
• The
group selects one example, which will usually be the basis of the analysis and
argumentation throughout the dialogue.
•
Crucial statements made by the participants are written down on a flip chart or
board, so that all can have an overview and be clear about the sequence of the
discourse.
The participants
of a NSD have to abide by the following rules:
• Each
participant's contribution is based upon what (s)he has experienced, not upon
what (s)he has read or heard.
• The
thinking and questioning is honest. This means that only genuine doubts about
what has been said should be expressed.
• It is
the responsibility of all participants to express their thoughts as clearly and
concisely as possible, so that everyone is able to build on the ideas
contributed by others earlier in the dialogue.
• Participants
should not concentrate exclusively on their own thoughts, they should make
every effort to understand those of the other participants and if necessary
seek clarification.
•
Anyone who has lost sight of the question or the thread of the discussion
should seek the help of others to clarify where the group stands.
•
Abstract statements should be grounded in concrete experience in order to
illuminate such statements.
•
Inquiry into relevant questions continues as long as participants either hold conflicting
views or have not yet reached clarity.
The NSD
will be organised and moderated by an authorised facilitator. This facilitator
has the following tasks: to look that participants mutually understand each
other, refer to their own experience, proceed step by step, remain focused on
the issue under discussion, participate equally in the dialogue, explain their
contributions thoroughly, substantiate their judgements, strive for consensus,
make progress in the dialogue. Moreover the facilitator documents the reasoning
of the dialogue. Finally, he/she will contribute to the evaluation by writing a
record of the NSD and will be interviewed for the evaluation.[4]
A group
of experts/stakeholders will participate in the NSD. These experts/stakeholders
are: researchers (e.g. active in stem cell research, psychologists,
sociologists, economists), physicians and other health care workers,
representatives of patients and their relatives as well as representatives of
self help groups, government, firms, religious, environmental and animals'
rights groups, statutory and private health insurance.
4.
Developing a new PTA method to debate ethical questions of modern science and
technology
In the
last 30 years a number of approaches of PTA have been explored (Hennen 1999,
Marris/Joly 1999), such as citizens' jury processes (Crosby 1996), citizens'
juries (Stewart et al. 1994), citizen panels (Hörning 1999) and consensus
conferences (Joss/ Durant 1995). In comparison with these broadly similar
approaches and the existing Technology Assessment (in the following TA) studies
on new biotechnologies the proposed project is innovative in the following
respect:
Contributing
to evaluation of PTA. PTA needs some kind of tested and evaluated procedure to
discuss ethical implications of XTP. Although a wealth of PTA have been carried
out so far on various technologies in the USA and Europe, at present evaluation
of PTA does hardly exist (as an exception c.f. Klüver et al. 2000). In
particular there is a lack of evaluation data on the impact of PTA. The
proposed project will create such data, in particular by systematically
interviewing participants before and after the NSD about their expectation and
experiences. Furthermore the proposed project will document and analyse the "resonance"
of the NSD in the public debate. Thus, evaluation will assess the value of the
NSD for PTA and its possible use in the debates surrounding other fields of
technology.
Introducing
a well-tested communication technique into PTA. An analysis of 16 PTA carried
out in EU-Member States shows, that the role and qualifications of the
facilitator as well as the methodology of discussion between
experts/stakeholders and laypersons is often only vaguely defined (Klüver et
al. 2000). The proposed project introduces a communication methodology (NSD)
into PTA, which is well established and tested in several areas. Furthermore,
the formalized training and certification of facilitators of the NSD assures
that they have the necessary qualifications to moderate such a process. The
proposed project will investigate the possibilities of this method to deal with
ethical questions of modern technology to underpin policy making.
Emphasizing
social learning. Klüver
et al. (2000) emphasize the significance and potential of social learning
processes of PTA. The proposed project stands in line with these efforts. The
NSD is a communicative method, which fosters social learning. The proposed
project will create a discursive space where experts/stakeholders and
laypersons will be able to reconcile conflicting claims and deliberate the
ethical implications of therapeutic cloning.
Stimulating
improvement of communicative patterns and abilities. The proposed NSD on XTP
differs from other methods of PTA in its goals. Like other approaches, NSD
opens a discursive space that enables choice. The NSD, however, is innovative
in its attempt to engender an open ethical debate and to make ethical actors
more aware of and sensitive to ethical questions of XTP as well as to improve
their ability to cope with and to communicate these questions to other actors.
Furthering
public participation in the debate on new biotechnologies. Most national and
international TA studies on new biotechnologies focussed so far on classical
TA, which strived for the improvement of decision-making by the production and
provision of knowledge. TA research in the last 15 years criticized this
TA-approach as ineffective (e.g. Albaek 1995), because it would simplify
policy-making processes and overvalue the potential impact of TA on these
processes. Policy-making does not follow rational choice but is a chaotic
process (Cohen et al. 1972, March/ Olsen 1989) in which scientific knowledge is
only one among others resources. As a consequence PTA advocates for broadening
TA and to include the perspectives of experts/stakeholders as well as
laypersons. This would improve the TA process on a cognitive, normative and
pragmatic level (Klüver et al. 2000). In contrast to that, very few existing
national and international TA studies on new biotechnologies have involved the
public in any significant way. The proposed project, which can be regarded as a
PTA project with focus on ethical questions, will increase public involvement
and broaden public debate by actively involving experts/stakeholders and
laypersons in a series of dialogue.
Involving
ethical actors into the debate on xenotransplantation. Ethical questions of modern
science and technology are not only within the competence and responsibilities
of (bioethics) experts, but are the responsibility of people directly involved
in relevant practical fields. We will call these groups "ethical
actors", i.e. professionals from research, medicine, nursing, social work,
public administration, insurance companies and interest groups as well as
patients and their relatives, who each will have to deal with the ethical
questions raised by XTP in their everyday life
(Chadwick
1999). The proposed project will broaden the debate on ethical questions of
xenotransplantation by actively involving these ethical actors. Unlike other
approaches to PTA the NSD will not involve randomly selected laypersons, but
deliberately selected ethical actors, which will be encouraged to reflect on
the ethical implications of XTP for their everyday life and work.
5.
Outline of the Research Project
The
following table gives an overview of the different steps of the research work:
Table 1
Working blocks of the proposed project
Working
block No. Title
1 Baseline Evaluation (Analysis of the Debate on XTP in
Each Participating
Country)
2 Analysis and Monitoring of International Debate
3 NSD
4 Evaluation of NSD
5 Final Report and Policy Options
6 Dissemination of Results of NSD and Project Results
The
heart of project is the evaluation of the Neo Socratic Dialogue. The evaluation
raises questions about its input, process, output and impact. Evaluation will
be based on participating observation (evaluators will observe the Neo Socratic
Dialogue), the records of the Neo Socratic Dialogue as well as ex-ante and
ex-post interviews with facilitators, participants and several key actors. The
first wave of follow up interviews will take place in the same week as the Neo
Socratic Dialogue. The second wave of follow up interviews will be carried out
2 to 3 months after the Neo Socratic Dialogue (see following list).
List of
Evaluation Questions 1st wave:
Input: •
Was it possible to enrol all relevant actors in the Neo Socratic Dialogue? If
not,
why not?
Process: • Which issues were debated? Which
lines of arguments were used during the Neo Socratic Dialogue? By whom? With
what results? Which coalitions as well as conflicts of interests did exist/
emerge? How did the group deal with them?
• Which problems arose?
• Was the process managed
efficiently?
Output:
• What results did the Neo
Socratic Dialogue have?
• Was consensus reached? If
not, why not? Was it possible to mark dissent?
• Was it possible to formulate
policy options?
• To what extent do
participants think that the Neo Socratic Dialogue achieved its
goals? Why?
• What experiences did
participants have in the Neo Socratic Dialogue? Where
their
expectations/motives/goals fulfilled? Why? Why not?
Impact:
• What consequences do
participants think that the Neo Socratic Dialogue will
have for their professional and
private everyday life?
• What consequences do participants think the Neo Socratic
Dialogue will have on the national and international XTP debate?
List of
Evaluation Questions: 2nd wave of follow up interviews
Input: • Was it possible to disseminate the results of the
Neo Socratic Dialogue into a wider discussion on XTP (a) within the
organisations the participants represented (b) to the general public?
Process: • In which ways were the results of
the Neo Socratic Dialogue brought in the XTP debate (e.g. newspaper articles
and other mass media, media of particular interest groups, governmental bodies,
parliament)?
Impact: • What consequences do participants think that the Neo
Socratic Dialogue will have for their professional and private everyday life?
• To which extent do participants in the Neo Socratic Dialogue
and other key persons attribute these changes to the Neo Socratic Dialogue?
The
next table (2) shows the methodologies used in each working block:
Table
2: Methodologies used in individual Working blocks
Working
block Methods
1 -
Content analysis of newspapers, magazines, policy papers
- Analysis of literature
- Secondary analysis of data
- Expert interviews
2 - Analysis of literature and
"grey literature" (e.g. conference papers, internet-web pages)
3 -
NSD
4 -
Analysis of records and documentation of the dialogue
- Baseline interviews with
participants (motives, expectations)
- Follow-up interview with participants
and facilitators of the NSD (2 waves)
- Interviews with other key
persons
- Comparison with
baseline-evaluation
- Content analysis of
newspapers, magazines, policy papers
5 -
Analysis of results of previous work packages
6 - Report and dissemination of results
(publication in scientific journals, presentation at conferences, press
conferences etc.)
The
project lasts for two years, starting in January 2002. It is carried out by
several scientific institutes in Austria, Germany and Spain.
For
further information contact Dr. habil. Beate Littig, Institute for Advanced
Studies,
A- 1060
Vienna, (littig@ihs.ac.at)
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List of
Abbreviations
IVF In Vitro
Fertilization
NGO Non
Governmental Organization
NSD Neo Socratic Dialogue
PTA Participatory
Technology Assessment
TA Technology
Assessment
This
work is based on a paper given at the 5th International
Summer Academy on Technology Studies, 13-19 July 2002, Deutschlandsburg,
Graz.
[1] XTP is based on several medical
and scientific developments, in particular: (a) progress in transgenics and
immunology, which have made possible the production of genetically modified
animal organs which are more compatible with the human immune system, and (b)
improvements in regulating the human immune response
[2] The project entitled
"Increasing Public Involvement in Debates on Ethical Questions of
Xenotransplantation"
is financed by the European Commission.
[3] By the end of 1997 the waiting
lists for transplantation in selected European countries totaled to: kidneys
30.392, heart 1.853, liver 1.755, lung 705, heart-lung 319, kidney and pancreas
267, pancreas 197. Numbers include: Austria, Belgium, France, Germany, Greece,
Luxembourg, Ireland, North-Italy, Portugal, Slovenia, Spain and UK (ETCO: 2000)
[4] Most facilitators of the NSD
completed academic training before they started their training as facilitators.
This training is based upon a (minimum) two years' experience as participant in
NSD. The practical and theoretical facilitator training lasts additional two to
three years and is supervised by an experienced facilitator (mentor).
Qualification emphasised in the training as facilitator include: pedagogic
competences, democratic attitudes, discourse ethics, psychological sense,
awareness about group dynamics and result orientation.