Table 2

The ethical analysis process inspired by the ‘Dilemma method’3 and ‘wide reflective equilibrium’5 14

Analysis processAdapted Dilemma method for research purposesCorresponding steps in the Dilemma method3
Presenting the situationPrior to the deliberation, MS presented written descriptions of four recurring ethically difficult situations from an observer perspective (Boxes 1–4). The situations were derived from between 1 and 4 of the 45 cases observed in the ethnographic study, and presented in a storytelling format.10 The condensed descriptions originated from field notes and interviews. Step 2. Presentation of the case. The case presenter is asked to provide short but thick description of the facts about a situation where he/she has experienced a moral issue at stake. The focus is on the ‘moment of heat’, which implies a situation experienced strongly as a moral dilemma within a specified timeline.
Formulating the moral questionFormulation of the moral question arising from the situation and two opposing normative options emerged through dialogue in the analysis group where the perspectives of the case presenter/observer and the interviewees were considered. MS also tried to bring the perspective of the patient. MS presented a preliminary analysis including field notes and interview transcripts (figure 1 and online supplemental file) which was scrutinised, shifting between formulation of the moral question/options and clarifying questions, facilitated by AS. Step 3. Formulating the moral question and Step 4. Clarification. The case presenter sketches the case, making the moral question explicit, for understanding of what is morally at stake. The facilitator helps to formulate the question by asking questions and also helps to formulate the dilemma as two opposing options (A and B). The facilitator invites participants to ask questions for clarification. The aim is to reconstruct the situation and to foster an understanding by imagining themselves in the shoes of the case presenter at the moment of heat.
Identifying perspectives, values and at stakeWe identified values related to the perspectives of those involved in the situation (figure 1). This was an iterative process shifting between articulated arguments and norms identified in the research data that reflected values that supported each specified normative option (A or B). Quotations from interviews and field notes were used to tease out the perspectives and values and demonstrate trustworthiness of the analysis (online supplemental file). Step 5: Analysing perspectives, values and norms. The facilitator asks the participants to jointly construct a list of relevant values and norms for each perspective (stakeholder). This includes values and norms either supporting option A or B.
Identifying the ethical conflictThe group identified which values were under pressure, including tensions both within and between values, and developed a joint formulation of the ethical conflict/s. Step 8. Dialogical inquiry. The facilitator helps the participants to find the values under pressure, whether both options are based on the same values or different values for the same option. Here the participants learn to see others’ perspectives.
Balancing between options and ethical principlesIn finding justifications for option A and B, we added ‘wide reflective equilibrium’5 14 in order to make general claims. We modified our considered judgements through an iterative process seeking coherence from a ‘wide’ scope of moral views (our own and those of participants), principles, theories and facts, moving the options closer to each other=equilibrium. and Step 7. Individual choice. The facilitator asks each of the participants to give personal viewpoints, answering questions about justifications for choosing option A or B. This enables learning from each other’s reasoning.