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Case Studies

More than 70 cases pair ethics concepts with real world situations. From journalism, performing arts, and scientific research to sports, law, and business, these case studies explore current and historic ethical dilemmas, their motivating biases, and their consequences. Each case includes discussion questions, related videos, and a bibliography.

A Million Little Pieces

James Frey’s popular memoir stirred controversy and media attention after it was revealed to contain numerous exaggerations and fabrications.

Abramoff: Lobbying Congress

Super-lobbyist Abramoff was caught in a scheme to lobby against his own clients. Was a corrupt individual or a corrupt system – or both – to blame?

Apple Suppliers & Labor Practices

Is tech company Apple, Inc. ethically obligated to oversee the questionable working conditions of other companies further down their supply chain?

Approaching the Presidency: Roosevelt & Taft

Some presidents view their responsibilities in strictly legal terms, others according to duty. Roosevelt and Taft took two extreme approaches.

Appropriating “Hope”

Fairey’s portrait of Barack Obama raised debate over the extent to which an artist can use and modify another’s artistic work, yet still call it one’s own.

Arctic Offshore Drilling

Competing groups frame the debate over oil drilling off Alaska’s coast in varying ways depending on their environmental and economic interests.

Banning Burkas: Freedom or Discrimination?

The French law banning women from wearing burkas in public sparked debate about discrimination and freedom of religion.

Birthing Vaccine Skepticism

Wakefield published an article riddled with inaccuracies and conflicts of interest that created significant vaccine hesitancy regarding the MMR vaccine.

Blurred Lines of Copyright

Marvin Gaye’s Estate won a lawsuit against Robin Thicke and Pharrell Williams for the hit song “Blurred Lines,” which had a similar feel to one of his songs.

Bullfighting: Art or Not?

Bullfighting has been a prominent cultural and artistic event for centuries, but in recent decades it has faced increasing criticism for animal rights’ abuse.

Buying Green: Consumer Behavior

Do purchasing green products, such as organic foods and electric cars, give consumers the moral license to indulge in unethical behavior?

Cadavers in Car Safety Research

Engineers at Heidelberg University insist that the use of human cadavers in car safety research is ethical because their research can save lives.

Cardinals’ Computer Hacking

St. Louis Cardinals scouting director Chris Correa hacked into the Houston Astros’ webmail system, leading to legal repercussions and a lifetime ban from MLB.

Cheating: Atlanta’s School Scandal

Teachers and administrators at Parks Middle School adjust struggling students’ test scores in an effort to save their school from closure.

Cheating: Sign-Stealing in MLB

The Houston Astros’ sign-stealing scheme rocked the baseball world, leading to a game-changing MLB investigation and fallout.

Cheating: UNC’s Academic Fraud

UNC’s academic fraud scandal uncovered an 18-year scheme of unchecked coursework and fraudulent classes that enabled student-athletes to play sports.

Cheney v. U.S. District Court

A controversial case focuses on Justice Scalia’s personal friendship with Vice President Cheney and the possible conflict of interest it poses to the case.

Christina Fallin: “Appropriate Culturation?”

After Fallin posted a picture of herself wearing a Plain’s headdress on social media, uproar emerged over cultural appropriation and Fallin’s intentions.

Climate Change & the Paris Deal

While climate change poses many abstract problems, the actions (or inactions) of today’s populations will have tangible effects on future generations.

Cover-Up on Campus

While the Baylor University football team was winning on the field, university officials failed to take action when allegations of sexual assault by student athletes emerged.

Covering Female Athletes

Sports Illustrated stirs controversy when their cover photo of an Olympic skier seems to focus more on her physical appearance than her athletic abilities.

Covering Yourself? Journalists and the Bowl Championship

Can news outlets covering the Bowl Championship Series fairly report sports news if their own polls were used to create the news?

Cyber Harassment

After a student defames a middle school teacher on social media, the teacher confronts the student in class and posts a video of the confrontation online.

Defending Freedom of Tweets?

Running back Rashard Mendenhall receives backlash from fans after criticizing the celebration of the assassination of Osama Bin Laden in a tweet.

Dennis Kozlowski: Living Large

Dennis Kozlowski was an effective leader for Tyco in his first few years as CEO, but eventually faced criminal charges over his use of company assets.

Digital Downloads

File-sharing program Napster sparked debate over the legal and ethical dimensions of downloading unauthorized copies of copyrighted music.

Dr. V’s Magical Putter

Journalist Caleb Hannan outed Dr. V as a trans woman, sparking debate over the ethics of Hannan’s reporting, as well its role in Dr. V’s suicide.

East Germany’s Doping Machine

From 1968 to the late 1980s, East Germany (GDR) doped some 9,000 athletes to gain success in international athletic competitions despite being aware of the unfortunate side effects.

Ebola & American Intervention

Did the dispatch of U.S. military units to Liberia to aid in humanitarian relief during the Ebola epidemic help or hinder the process?

Edward Snowden: Traitor or Hero?

Was Edward Snowden’s release of confidential government documents ethically justifiable?

Ethical Pitfalls in Action

Why do good people do bad things? Behavioral ethics is the science of moral decision-making, which explores why and how people make the ethical (and unethical) decisions that they do.

Ethical Use of Home DNA Testing

The rising popularity of at-home DNA testing kits raises questions about privacy and consumer rights.

Flying the Confederate Flag

A heated debate ensues over whether or not the Confederate flag should be removed from the South Carolina State House grounds.

Freedom of Speech on Campus

In the wake of racially motivated offenses, student protests sparked debate over the roles of free speech, deliberation, and tolerance on campus.

Freedom vs. Duty in Clinical Social Work

What should social workers do when their personal values come in conflict with the clients they are meant to serve?

Full Disclosure: Manipulating Donors

When an intern witnesses a donor making a large gift to a non-profit organization under misleading circumstances, she struggles with what to do.

Gaming the System: The VA Scandal

The Veterans Administration’s incentives were meant to spur more efficient and productive healthcare, but not all administrators complied as intended.

German Police Battalion 101

During the Holocaust, ordinary Germans became willing killers even though they could have opted out from murdering their Jewish neighbors.

Head Injuries & American Football

Many studies have linked traumatic brain injuries and related conditions to American football, creating controversy around the safety of the sport.

Head Injuries & the NFL

American football is a rough and dangerous game and its impact on the players’ brain health has sparked a hotly contested debate.

Healthcare Obligations: Personal vs. Institutional

A medical doctor must make a difficult decision when informing patients of the effectiveness of flu shots while upholding institutional recommendations.

High Stakes Testing

In the wake of the No Child Left Behind Act, parents, teachers, and school administrators take different positions on how to assess student achievement.

In-FUR-mercials: Advertising & Adoption

When the Lied Animal Shelter faces a spike in animal intake, an advertising agency uses its moral imagination to increase pet adoptions.

Krogh & the Watergate Scandal

Egil Krogh was a young lawyer working for the Nixon Administration whose ethics faded from view when asked to play a part in the Watergate break-in.

Limbaugh on Drug Addiction

Radio talk show host Rush Limbaugh argued that drug abuse was a choice, not a disease. He later became addicted to painkillers.

U.S. Olympic swimmer Ryan Lochte’s “over-exaggeration” of an incident at the 2016 Rio Olympics led to very real consequences.

Meet Me at Starbucks

Two black men were arrested after an employee called the police on them, prompting Starbucks to implement “racial-bias” training across all its stores.

Myanmar Amber

Buying amber could potentially fund an ethnic civil war, but refraining allows collectors to acquire important specimens that could be used for research.

Negotiating Bankruptcy

Bankruptcy lawyer Gellene successfully represented a mining company during a major reorganization, but failed to disclose potential conflicts of interest.

Pao & Gender Bias

Ellen Pao stirred debate in the venture capital and tech industries when she filed a lawsuit against her employer on grounds of gender discrimination.

Pardoning Nixon

One month after Richard Nixon resigned from the presidency, Gerald Ford made the controversial decision to issue Nixon a full pardon.

Patient Autonomy & Informed Consent

Nursing staff and family members struggle with informed consent when taking care of a patient who has been deemed legally incompetent.

Prenatal Diagnosis & Parental Choice

Debate has emerged over the ethics of prenatal diagnosis and reproductive freedom in instances where testing has revealed genetic abnormalities.

Reporting on Robin Williams

After Robin Williams took his own life, news media covered the story in great detail, leading many to argue that such reporting violated the family’s privacy.

Responding to Child Migration

An influx of children migrants posed logistical and ethical dilemmas for U.S. authorities while intensifying ongoing debate about immigration.

Retracting Research: The Case of Chandok v. Klessig

A researcher makes the difficult decision to retract a published, peer-reviewed article after the original research results cannot be reproduced.

Sacking Social Media in College Sports

In the wake of questionable social media use by college athletes, the head coach at University of South Carolina bans his players from using Twitter.

Selling Enron

Following the deregulation of electricity markets in California, private energy company Enron profited greatly, but at a dire cost.

Snyder v. Phelps

Freedom of speech was put on trial in a case involving the Westboro Baptist Church and their protesting at the funeral of U.S. Marine Matthew Snyder.

Something Fishy at the Paralympics

Rampant cheating has plagued the Paralympics over the years, compromising the credibility and sportsmanship of Paralympian athletes.

Sports Blogs: The Wild West of Sports Journalism?

Deadspin pays an anonymous source for information related to NFL star Brett Favre, sparking debate over the ethics of “checkbook journalism.”

Stangl & the Holocaust

Franz Stangl was the most effective Nazi administrator in Poland, killing nearly one million Jews at Treblinka, but he claimed he was simply following orders.

Teaching Blackface: A Lesson on Stereotypes

A teacher was put on leave for showing a blackface video during a lesson on racial segregation, sparking discussion over how to teach about stereotypes.

The Astros’ Sign-Stealing Scandal

The Houston Astros rode a wave of success, culminating in a World Series win, but it all came crashing down when their sign-stealing scheme was revealed.

The Central Park Five

Despite the indisputable and overwhelming evidence of the innocence of the Central Park Five, some involved in the case refuse to believe it.

The CIA Leak

Legal and political fallout follows from the leak of classified information that led to the identification of CIA agent Valerie Plame.

The Collapse of Barings Bank

When faced with growing losses, investment banker Nick Leeson took big risks in an attempt to get out from under the losses. He lost.

The Costco Model

How can companies promote positive treatment of employees and benefit from leading with the best practices? Costco offers a model.

The FBI & Apple Security vs. Privacy

How can tech companies and government organizations strike a balance between maintaining national security and protecting user privacy?

The Miss Saigon Controversy

When a white actor was cast for the half-French, half-Vietnamese character in the Broadway production of Miss Saigon , debate ensued.

The Sandusky Scandal

Following the conviction of assistant coach Jerry Sandusky for sexual abuse, debate continues on how much university officials and head coach Joe Paterno knew of the crimes.

The Varsity Blues Scandal

A college admissions prep advisor told wealthy parents that while there were front doors into universities and back doors, he had created a side door that was worth exploring.

Providing radiation therapy to cancer patients, Therac-25 had malfunctions that resulted in 6 deaths. Who is accountable when technology causes harm?

Welfare Reform

The Welfare Reform Act changed how welfare operated, intensifying debate over the government’s role in supporting the poor through direct aid.

Wells Fargo and Moral Emotions

In a settlement with regulators, Wells Fargo Bank admitted that it had created as many as two million accounts for customers without their permission.

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A Casebook of Strategic Corporate Social Responsibility pp 1–9 Cite as

Human Values in Corporate Social Responsibility: A Case Study of India

• Aruna Das Gupta 4  
• First Online: 04 December 2021

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Part of the book series: CSR, Sustainability, Ethics & Governance ((CSEG))

Values provide an in-built standard of reference and judgement for our actions. Values are by no means static, permanent and unchangeable. We may have good reasons for abandoning a value or incorporating a new one in our system, but that process involves its own justification and careful reckoning. The corporate sector in India is dominated by family firms, not only in terms of overall numbers, but also with respect to representation among the largest companies. Some of the more prominent of the family controlled business houses have a history of corporate philanthropy and involvement in community development dating back to the last century and the early part of this century. These commitments, in most instances instilled by the founder of the firm, have expressed themselves in a wide variety of areas.

Author Note: This chapter draws from the author’s previous publication published in International Journal of Business Ethics in Developing Economies; Vol 1; Issue 1;July, 2012. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

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Das Gupta, A. (2022). Human Values in Corporate Social Responsibility: A Case Study of India. In: Das Gupta, A. (eds) A Casebook of Strategic Corporate Social Responsibility. CSR, Sustainability, Ethics & Governance. Springer, Singapore. https://doi.org/10.1007/978-981-16-5719-1_1

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Bio-Ethics and One Health: A Case Study Approach to Building Reflexive Governance

Antoine boudreau leblanc.

1 Bioethics Programs, Department of Social and Preventive Medicine, Public Health School, Université de Montréal, Montréal, QC, Canada

Bryn Williams-Jones

Cécile aenishaenslin.

2 Department of Pathology and Microbiology, Faculty of Veterinary Medicine, Université de Montréal, Montréal, QC, Canada

Associated Data

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

Surveillance programs supporting the management of One Health issues such as antibiotic resistance are complex systems in themselves. Designing ethical surveillance systems is thus a complex task (retroactive and iterative), yet one that is also complicated to implement and evaluate (e.g., sharing, collaboration, and governance). The governance of health surveillance requires attention to ethical concerns about data and knowledge (e.g., performance, trust, accountability, and transparency) and empowerment ethics, also referred to as a form of responsible self-governance. Ethics in reflexive governance operates as a systematic critical-thinking procedure that aims to define its value: What are the “right” criteria to justify how to govern “good” actions for a “better” future? The objective is to lay the foundations for a methodological framework in empirical bioethics, the rudiments of which have been applied to a case study to building reflexive governance in One Health. This ongoing critical thinking process involves “mapping, framing, and shaping” the dynamics of interests and perspectives that could jeopardize a “better” future. This paper proposes to hybridize methods to combine insights from collective deliberation and expert evaluation through a reflexive governance functioning as a community-based action-ethics methodology. The intention is to empower individuals and associations in a dialogue with society, which operation is carried out using a case study approach on data sharing systems. We based our reasoning on a feasibility study conducted in Québec, Canada (2018–2021), envisioning an antibiotic use surveillance program in animal health for 2023. Using the adaptive cycle and governance techniques and perspectives, we synthesize an alternative governance model rooted in the value of empowerment. The framework, depicted as a new “research and design (R&D)” practice, is linking operation and innovation by bridging the gap between Reflexive, Evaluative, and Deliberative reasonings and by intellectualizing the management of democratizing critical thinking locally (collective ethics) by recognizing its context (social ethics). Drawing on the literature in One Health and sustainable development studies, this article describes how a communitarian and pragmatic approach can broaden the vision of feasibility studies to ease collaboration through public-private-academic partnerships. The result is a process that “reassembles” the One Health paradigm under the perspective of global bioethics to create bridges between the person and the ecosystem through pragmatic ethics.

Introduction

The greatest health, social, and environmental challenges of the twenty-first century, such as antibiotic resistance, zoonotic pandemics, and climate change, require a “complexification” of monitoring and management programs ( 1 ). One Health aiming at the convergence of human, animal, and environmental health seeks to operationalize this complexity—in terms of contextualization, participation, and adaptation—through the integration of adaptive governance systems in evaluation, surveillance, and intervention ( 2 – 4 ). However, such programs should also be based on the practice of empowerment ethics: a self-critical examination, a receptivity to criticism, and a critical duty to change in order to judge and implement “good” learning for a “better future.” As understood by Van Rensselaer Potter (1911–2001; who coined the term bioethics in 1970), empowerment must lead to responsibility as a duty, not only to autonomy as a right for self-governance which tends to separate the singular will from biological facts ( 5 , 6 ). First, em-power ( in/within power) means managing and preventing the power, knowledge, and interest dynamic that transcends and modulates people and “community-will” and behavior: a “bottom-up” approach. Second, empowerment must lead individuals and communities to make their own changes, as autonomous and self-determining agents who acknowledge local values and constraints as criteria for change. Third, power must lead to awareness of our individual and social actions, which should also lead to self-responsibility and even to accountability mechanisms: an “abductive” approach ( 7 ) 1 .

Data sharing processes, biosurveillance programs, and multiscale analysis are techno-intellectual systems; they are examples of Edgar Morin's complexity concept. Managing complex systems requires pragmatic methodologies and ethics ( 9 ) because the willingness of people to consent to and participate in these systems changes over time ( 10 , 11 ). An ethic (as a code) is useful both for transparency and as a means to produce a climate of trust that is suitable for discussion, while ethical analysis (as a methodology) is a key component to avoid the emergence of oppressive powers, to reduce bias, and to envision a “better future” ( 12 , 13 ). For instance, feedback from One Health surveillance programs such as benchmarking is appreciated by practitioners where it improves their practices, until it raises ethical issues, notably, risks of bias and confidentiality breach. Empowerment ethics (as a discipline), then, is about finding ways to communicate to produce a collective narrative that gives meaning and orientation to actions and is especially important when there is a diversity of terminologies and interdisciplinary perspectives. In this view, communication must go beyond the person-to-person exchange and become a collective process ( 14 ).

Predictive and mechanistic models are no longer sufficient to address health problems in all their complexity ( 15 ). Callon et al. ( 14 ) propose that we move from risk assessment and management to a social process that integrates more broadly uncertainty. One Health should therefore move its problem-solving strategies “upstream,” before program ideation, which we will call here the “assemblage” of its knowledge, notably, its technologies, its methods, even its paradigms ( 16 , 17 ). Such One Health ethics, which would progress through communication and knowledge systems, would enable stakeholders to question and advance their understanding and positioning. However, managing the “cross” thematic (e.g., human, animal vs. environment studies), the “inter” disciplines (e.g., medicine, technology, and law), the “trans” sectorial (e.g., the relationship between experts and non-specialists), and the “multi” scale viewpoints (e.g., human, beings, and things as organizational units) is a fundamental barrier to the successful implementation of One Health programs ( 18 – 20 ).

The objective is to lay the foundations for a methodological framework in empirical bioethics, the rudiments of which have been applied to a case study to building reflexive governance in One Health. This case made it possible to study the functioning of empowerment ethics in the development cycles of One Health surveillance programs. The proposed case sought to implement an antibiotic use surveillance program in animal health (2018–2021) in Quebec, Canada. Data from this surveillance system in public health could allow both scientific research and informed decision-making. The research question here, in bioethics, is about the promotion and education of critical thinking in technology and health, not only of scientists and policymakers but of all stakeholders. Building on a pragmatic approach to bioethics, this reasoning is driven by, first: How could empowerment ethics ease the “bridging” between cognitive and collective? From a synthesis of One Health methodologies and paradigms, the reasoning continues with a framework laying out the theoretical rudiments for a hybrid method to understand: How can we embed person-to-person dialogue in a collective assemblage to engage social groups in a negotiation process? Dialogue is supported by reflective critical thinking approaches, while social negotiation moves this cognitive to the level of collective interaction supported by ethical deliberation approaches. Finally, learnings from the case study will give answers to How can a community of beings and things become “reflexive,” conscious, and responsible, i.e., the “ought to be” empowered?

Site and Approach

Case study of antimicrobial surveillance and data governance.

Since 2017, the Government of Quebec has been considering developing surveillance programs that integrate efforts in health prevention between several ministries and sectors (see the Government Policy on Health Prevention; GPHP). This type of policy could be improved by its connection with several advanced theories in various fields that converge in practice under the perspective and terminologies of One Health and sustainable development. A challenge for One Health, in such a policy context, is to deepen the decision-maker's understanding of the pertinent theories while avoiding reduction to a set of expert buzzwords or jargon that then complicate translation into practical terms ( 21 ).

One of the policy objectives set by the Government was to develop a well-articulated program that had community-based meaning and criteria (e.g., feasible and acceptable, understood as useful, and sustainable) for a surveillance system of antibiotic use in animal health (agriculture and pets). Its program arose in a social context where several sectors, particularly in human, animal, and environmental health, had already implemented initiatives dealing with outbreaks, pharmaceuticals, and, notably, antimicrobial governance based on systems of information and communication technologies (SICT) used for surveillance purposes. In animal health, different committees, associations, and groups are involved in leading these reflections through participation in formal and informal working groups. These activities aim to produce detailed application procedures that would then be laid out in an action plan for the management of antibiotic use, surveillance, and governance for all sectors of veterinary practice and food production 2 . Many initiatives were more local (microscale) and launched by individuals or groups affiliated with the industry, academia, and professional associations, while others were broader (macroscale), and initiated by governments and civil society as networks (market, culture, values, etc.). The resulting initiatives are designed to push for change on both a micro and macro scale. But for such change to be effective, it requires a mixture of approaches, including both “top-down” political incentives (regulations, financing, and infrastructure) and “bottom-up” processes, including democratic mechanisms.

In light of these different initiatives, the Ministère de l'agriculture, des pêcheries et de l'alimentation (MAPAQ) mandated a feasibility study of the implementation of a surveillance program on the use of antibiotics in animals in Quebec (2018–2021). Several recommendations emerged from the resulting consensus-building process (2019–2020) within the veterinary and agricultural community, notably:

• To build data systems and information platforms and their use based on trust,
• To co-construct a common normative language,
• To design a collaborative governance regime to shape the functioning of the program.

Aiming to implement a methodology for this collaborative collective thinking, the multidisciplinary team in charge of the feasibility study made a distinction between “consultation” and “concertation” to unpack the consensus-building nature of the methodological process. The consultation aims to gather information from a group to inform experts in developing the “best” model possible (the feasibility aspect), while concertation seeks for consensus among a group to deliberate about which criteria are “best” (values and vision), in order to give an acceptable orientation to the developing model (see here the clear distinction between descriptive and appreciative knowledge further developed in the last section).

The concertation phase of the feasibility study, which began with 60 representatives, eventually brought together 100, an extensive recruitment process aimed at saturating the perspectives covered by the different sectors of activity (industry, academia, government, association, order, etc.), practice (pork, poultry, small and large ruminants, pets, and sports animals), and professions (breeders, veterinarians, nutritionists, researchers, informatics experts, etc.). The two concertation events made it possible to collectively deliberate on the overall vision and were then followed by 12 consultations that brought together different stakeholders in small groups (6–16 participants per group) to deepen the discussion. Subsequent focused individual interviews made it possible to add reflexive details to the perspectives (challenges and facilitators) of key actors involved in the process (e.g., data, software, IT support providers). Human and environmental sectors (professional, academic, political, and industrial) were not the focus of the discussions; instead, the focus was on the ethical challenge of implementing a new technosocial program and developing a policy to manage the use of antibiotics in animal health. Nevertheless, many of the participants were invited to group discussions and interviewed separately to further explore their views on how the animal health situation is nested within the larger context of One Health. Ethics approval was received for the research phase of this project from the University Research Ethics Committee (anonymous); all participants were informed of the nature and scope of the project, the confidentiality mechanisms in place, and gave their consent to participate.

A Pragmatic Bioethics Approach

One of the notable challenges of contemporary methodologies is to account for multi-scale relationships, building a bridge between the individual, the social, and the global. Ten Have ( 22 ) introduces the community perspective as an appropriate approach to operating global bioethics. By examining recent conceptual advances in pragmatic ethics and empirical bioethics, we propose here the operation of a community-based action-research (translated in action-ethics). According to Jonathan Ives ( 23 ) synthesis of methodologies in empirical bioethics ( 24 , 25 ), an ethical analysis of a complex situation should be reflexive and focus on the empirical case under study, and not be biased by it, and so risk (over)valuing preexisting injustices rather than criticizing them ( 26 ). A multidisciplinary team of academics (veterinary medicine, bioethics, and law) and practitioners (veterinary, farmers, millers, association, and industry) contributed extensively to the empirical bioethics research project, which was embedded within and thus part of the above-mentioned feasibility study.

The team located at the Faculté de Médecine Vétérinaire at the Université de Montréal (FMVUM) was mandated by MAPAQ to conduct a large-scale empirical and social project. By reviewing, commenting upon, and critiquing the rudiments of this philosophical model, both the team and participants contributed to testing and enriching the model, as intended by good reflective practice. As an employee for this project, one of the authors, Boudreau LeBlanc (a Ph.D. student and empirical bioethicist in training), was given the task to develop a model to manage the ethical challenges with deploying consultation and concertation processes and to ensure the reflexivity of the experts and the deliberation of the collective (e.g., power relations, naturalistic, and philosophical reasoning biases). One solution to the challenge of bridging reflexivity and deliberation was to include the micro, meso, and macroscales in discussions, although this also introduced other ethical challenges, namely the subjectivity of each actor (e.g., their values, knowledge, and interests). Thus, it was obvious that a collective ethic was needed to set ground rules so that the actors could cooperate and co-construct the governance system. The feasibility study (2018–2021) conducted in Quebec, Canada, to evaluate the possible implementation of a monitoring system for the use of antibiotics in veterinary medicine was thus an ideal opportunity to study in situ how such a collective ethic could be implemented in a complex system in a way that leads to empowerment ( 27 , 28 ).

Ethics is crucial to guiding new means of collaboration through public-private-academic partnerships, but it also requires empirical methodologies such as those developed in bioethics and pragmatism. Pragmatic ethics is about negotiating conflicting positions that emerge from empirical situations (within the community) and are made accessible through philosophical reasoning ( 26 , 29 ). Ethics of science means (here, as a discipline) supporting the scientific community to question itself, individually as the responsible conduct of researchers, but also collectively through critiques of the nature of scientific research (in general and related to specific projects). Ethics (as in codes) is involved in the development of appreciative criteria and knowledge to judge conduct, evaluate the purpose, and propose appropriate governance mechanisms. Such an understanding of ethics could favor trust and lead to an agreement between experts and the community, which could then accelerate change. However, any criteria also need to progress through time via both rational reflexivity (a cognitive process) and collective deliberation (a social process). Without pragmatism in the ethics of science, researchers and communities will struggle to produce effective and adaptive networks, norms, and actions because the interests of the various stakeholders (as social or disciplinary) will not be articulated or aligned ( 5 , 6 ).

A practice of empowerment ethics should be developed by and for a community ( 30 , 31 ). In this Potterian One Health framing, empowerment ethics is presented as an alternative mode of governance that returns power to the key stakeholders involved, so that they can become actors of and responsible for the changes with which they will live ( 6 ). Such an understanding of ethics could provide a valuable foundation on which to build collaborative governance regimes that transcend academic, industrial, and public service limitations ( 32 , 33 ). One of the cores aims of empowerment ethics is to build and maintain the trust of the key stakeholders involved in the program ( 34 , 35 ). According to Davet et al. ( 36 ), three methodological processes should be used:

• Design a practical model of change,
• Set up a collaborative governance structure early in the thinking process,
• Co-construct a common language to give purpose to, and a framework for, points 1 and 2.

As theorized by Latour ( 16 ), such a method necessitates a socio-episteme-methodological approach, the sort which is embodied in One Health and, more broadly, in bioethics ( 37 ). In practice, such an approach needs to be distributed at various scales of observation, at all levels of knowledge, and across several analytical dimensions, explained by Callon et al. ( 14 ) as three intertwined operations of translation and by Latour ( 16 ) as the metrological manner of constructing scientific standards (see the synthesis tool in the last section).

This ethics-science-society organizational approach highlighted in Beever and Whitehouse's ( 37 ) work in Potterian bioethics is conceptually close enough to Morin's philosophy to be qualified as a “Penser Global” (“Think Global,” not “worldwide,” 2015) or more deeply to fall under the paradigm of human complexity ( 38 ), and requires an extended understanding of the sciences and an answer to the question: what is “truly” feasible? In a similar vein, the UN ( 39 ) has called for a science of sciences to develop an ecosystem of knowledge as part of ongoing critical thinking about science and policy. In this view, science must be seen as a complex (eco)system for which the “rules of the game” change over time as society “evolves” (e.g., changes in political, social, and physical laws). Consequently, we must also be cognizant of emerging biases and inequities, and so develop a practice in ethics of sciences and as an “ethic of ethics” based on a community-based empowerment ethics practice ( 40 ). Potter ( 41 ) highlighted the importance of supporting such collective ethics of science as a frame to determine what is “feasible” (i.e., the right knowledge and technical standards). This practice of ethics should thus be understood as a form of pragmatic “action-ethics” grounded in a strong critical thinking process that emerges from people and the social. This action-ethics practice combines several approaches proposed by empirical bioethics scholars ( 26 , 29 ): “inter-ethics” ( 42 ), “in-action ethics” ( 43 ), and “ethics ecosystem” ( 44 ).

The Framework

Assembling the methods.

To build reflexive governance for SICTs development, we propose a community-based action-ethics methodology. The methodology bridges expert evaluation and collective deliberation in a way to empower individual stakeholders and engage group leaders ( Figure 1 ). Project management in Research and Development must shift to a more integrative practice, coined here as adaptive Reflective-Evaluative-Deliberative cycle.

Framework in research and innovation to building reflexive governance for the responsible development of systems of information and communication technologies, hybridizing three types of reasoning are key to “reassembling” scientific paradigms in practice: 1. Evaluative as descriptive and traceable, 2. Deliberative as appreciative and prospective, and 3. Reflexive as knowledge balancing (1–2) to responsible policy. Reassembling is a “complexus” process (literally “being woven together”), here seen as an adaptive cycle and through the lens of the Huxtable and Ives framework in bioethics to support project management: 1. “Mapping” the ideas to generate a hybrid ethical theory, 2. “Framing” to be reliable to a case, and 3. “Shaping” a proper (micro) normative theory for change. We highlight the importance of ever questioning the whole process.

Evaluation (literally “the action of defining the value of”) is a key technique for bridging philosophy, science, and society through practical reasoning methods. Evaluation and deliberation must be conceived as independent methods given their distinct philosophical criteria and end (epistemology and teleology). To do so, reflexivity tools are crucial to avoid logical fallacies and to deepen and enrich the program value. However, these three methods benefit from being driven in parallel as interdependent methodologies ( 23 , 42 ). Therefore, the expertise in One Health should be based on more advanced knowledge of social science and philosophy, which should lead to an applied “social ethics.” The bioethicist can help bridge political, social, and scientific insights within and outside organizations ( 42 ). These insights must be based on empirical observations and expert advice, namely a “co-construction” perspective hybridizing qualitative methods such as Delphi, concertation, participative study, and focus groups 3 .

Deliberation (literally “to discuss collectively in order to decide”) is a common reasoning process in day-to-day life. Deliberation aims at collectively examining, justifying, and questioning reasoning. However, political and professional deliberations should be about ethical justification, not scientific or political ones, or any private interest. Deliberation can be based on critical and evaluative reasoning, which would lead to a ( disciplined ) form of “collective ethics.” Collective ethics could become an end for deliberation. Deliberative reasoning has a foot in the political and scientific “arena,” both of which may or may not be conducted ethically. Collective ethics seeks to establish “ground rules” as starting principles that are analyzed from multiple angles (all stakeholders), including from the sciences and society as a “hybrid forum” ( 14 ) 4 . Deliberation benefits from qualitative methods (including those mentioned above), especially when rooted in political and humanistic approaches, such as hermeneutics ( 42 ). However, deliberation must not intend to “test” ideas or even describe a group's narrative, as would be the case of these methods in empirical sciences. The aim is to reassemble , seek consensus and acceptability on the proposal, and deepen the collective reasoning. Expert understanding and scientific knowledge must be mobilized in recognition of their descriptive and analytical value during such reflective processes.

Reflexivity, as the quality and method for critical thinking, connects the real world (empirical) to abstract reflection (intellectual), allowing feedback from both sides: evaluation and deliberation. But reflexivity is tied to the (epistemological) challenges of both philosophy and science, to which pragmatism provides some answers. Judging reflexive thoughts is a matter of dialogues, integrity, and trust, even of bidirectional relationships, of a continuous search for consensus, and of collective duty to empower people to question these “thoughts.” Expertise from philosophy or science must be careful not to become a (normative) dictature ( 40 ), even under urgent calls for sustainability, precautionary, solidarity, and responsibility in public health ( 11 , 48 – 50 ). The competency of experts must be balanced with humility and compassion ( 51 ), or localism and experimentalism ( 52 ). The objective of reflexivity in pragmatism is to find ever better courses of action, the quality of which is established in light of the future (feedbacks). This “prospective science” is intellectualized as experiential learning (yet past), with the aim of archiving the common ground for cooperation, such as a vision, models, and theories (even formal agreements) of change ( 5 , 39 , 53 ).

Apply a Balancing Approach

Following Huxtable and Ives' ( 26 ) framework in empirical bioethics, the process is divided into three phases to organize the reasoning:

• “Mapping” the ideas to generate a hybrid ethical theory,
• “Framing” to be reliable to a case,
• “Shaping” is a proper (micro) normative theory for change.

In A Companion to Bioethics ( 54 ), John Arras understands this framing in bioethics as “casuistry,” an approach in ethics: “the [technics] of applying abstract principles, maxims or rules to the concrete case.” The “empirical case” (as used here) is a social collective on the edge of transformation, meaning to be reorganized or “reassembled” according to Latour's work ( 16 ) based on a unifying issue, here antimicrobial governance and digitalization. This Latourian perspective embeds the observer in the systems he is observing, which opens the possibility of a case study in empirical bioethics, focusing on the (intellectual) system of values characterizing and contextualizing these observers (based on a Ph.D. project in bioethics). To propose an ethical strategy for “managing” this system of values, which means deepening and seeking consensus among various interests, we adopt the logic of adaptive cycles in management, the one that gives rise to the perspective of adaptive governance ( 55 ).

Critical reflexivity is understood here as “balancing” reasoning. Reflexivity is a negotiating process between empirical data from interdisciplinary methods and rational insight from philosophical methods in order to find feasible solutions and long-term acceptable actions ( 6 , 23 ). “Balancing” means having facts and values as two samples for which we do not know a priori their weight. We must experience this balancing (as an ongoing process) to ground the normative knowledge that should support decision-making. “Fact” means knowledge and empirical observations ( in situ : resources, capacities, power, and will), while “value” is about philosophical questioning and self-critical reasoning. Values are given to qualifying, notably uncertainty, bias, even the usefulness and successfulness of decisions ( 56 ). Theories of value, as academic knowledge, archive notable critical reasoning paths. However, values, criticism, and reflexivity are also subjective.

Reflexive balancing, coined by Ives ( 23 ) with Heather Draper ( 25 ), is an ethical (meta)analysis combining methodology for interdisciplinary and critical reflexivity. The outcome can support self-governing processes that empower the community. At the collective level, reflexive balancing must begin at the start during initial planning, sampling, and questioning ( Figure 1 ). This upstream ethical reflexivity and expertise have included the active role of FMVUM team members to conduct the interdisciplinary methodology. This means diversifying the disciplinary assets at the start; here meaning expertise in ethics, laws, technologies, and medicines, and more broadly community representatives. Note that facts and values are not dependent—as in “reflexive equilibrium” ( 23 , 57 )—but interdependent through the reasoning process. For example, sometimes facts justify actions that go far beyond what is acceptable and thus go against accepted human values; their application changes the “rules of the game.” Alternatively, values can justify change prior to evidence, as articulated in the principles of precaution, solidarity, or responsibility.

Social negotiation, a key concept of the deliberation reasoning ( 58 ), can support ethical analyses when applied to the evaluation of multi-actor systems of values as a “collective thinking process.” Ethical negotiation is enriched by co-construction approaches conducted at all steps of the program development and by acknowledging multiple scales of translation: here the expert, team, and community ( 14 ). At the expert level, the approach of Abma et al. ( 42 ) to bioethics was used to interact with actors (the Ph.D. student as a formal member of the FMVUM team) to deepen their understanding and positioning. At the team level, Samuel et al. ( 44 ) coined the model of “The Ethics Ecosystem” to empower stakeholders in the development of the governance system structure, functioning, and purpose, notably the influence of allocation of financial resources, conflicts of interest and shared responsibilities. At the (collective and biotic) community level, Ives' ( 23 ) methodology for empirical ethics provides guidance on how to negotiate stakeholder values and avoid fallacious reasoning through a reflexive, interdisciplinary, and pragmatic balancing method.

In summation, how to connect reflexivity and deliberation in One methodology with One (collective) goal? Where should ethics occur in decision-making processes to empower critical thinking from individuals to the whole organization? Is it by the mandating government (a department, e.g., MAPAQ), the responsible team (within the university, e.g., FMV), or individuals (representatives of private interests)? The three kinds of reasoning—reflexive, evaluative, and deliberative—integrate distinctive approaches from empirical bioethics into the project management process ( Figure 1 ). All three steps refer to methods that have distinct philosophical standpoints (i.e., qualitative criteria of scientificness and ends). For instance, deliberation is about collective discussions and consensus-seeking, while evaluation refers to critical analysis (scientific, political, economic, etc.), but must also be ethical, meaning self-critical reflexivity. This linkage implies the opening of a dialogue “in the field” between experts, here in veterinary practitioners, epidemiology, data science, technology governance, etc., with different social perspectives (professional orders, industrial associations, interest groups, universities, government, etc.). In the spirit of the community-based action-ethics methodology, the intellectual assemblage must be conceived prior to the case study as an applied framework (Phase 1: Mapping). The goal is to anticipate core issues, first by thought experiments ( 59 ). Pragmatism, based on the relationship between theory and practice, focuses on courses of action and uses reflexivity to question and advance them (phase 2: framing). The outcome of pragmatism is empowerment often based on communication and/or education tools (Phase 3: Shaping).

Applying the Framework

Deliberation is part of decision-making processes and in the right “location” to position ethics in governance. Mapping means here, first, acknowledging an adequate theory in ethics (see above A Pragmatic Bioethics Approach) and, second, choosing the best deliberative strategies to put it in practice (see below). A hybrid methodology that connects reflection, deliberation, evaluation and decision in a systemic process is detailed in Figure 2 . However, deliberation can become a way to scale up critical reasoning at the social level if mobilized for a collective ethic, rather than to plan the technicalities of the operationalization of a project. To be systemic, such a process must “exist” as a core functioning process of a community. Although to be effective, deliberation must be constructive and useful for stakeholders. Ethnographic methods can be used to plan and design the fieldwork to ensure the deepening of deliberative reasoning ( 60 ).

Assembling the methods for collective thinking to orient the project of a data and information system for antimicrobial surveillance in Quebec: A decision-making process that locates ethics by default at each stage requires a reassembling of the program development cycle of conceptualization up to implementation and evaluation. This decision-making process becomes community-based by the bridge it creates between deliberation (Step 2) and reflexivity upstream, i.e., before and during the conceptualization phase. This “preparatory phase” becomes a process of planning (Step 1) and evaluating (Step 3) decisions in order to co-build collective ethics (for/by the community) that empowers individuals to think critically and the community to critically evaluate based on dialogue, concertation, and a proper environment for knowledge translation.

This reflexive “roadmap” with several checkpoints ( Figure 2 ) guided the feasibility study (2018–2021) conducted in Quebec, Canada, to evaluate the possible implementation of a monitoring system for the use of antibiotics in veterinary medicine. The deliberation process initiated in 2019 with a “Proposition” (Step 1) toward in-depth consultations and interviews to coin collaborative principles (2019–2022, Step 2), as well as the work of expertise to “engineering” a model (2019–2022, Step 3) to ethically negotiate at multi-scale (micro vs. macro) perspectives on conflicting discourses ( 61 ). Such roadmaps are useful for strategic and ethical leadership. The iterative process is key to building leadership in a system involving shared responsibilities between coordination (the team), several stakeholders, and policymakers. Leadership is about positioning and evolving, which means giving a clear, yet visionary, position about: Who has a job to do? To what end? and For whose interests? ( 34 , 62 , 63 ).

Setting the Scene

Setting the scene ( Figure 2 , Step 1) is the first step for thinking about change ( 64 ). In the case study, this stage began in 2019 with concertation that brought together 60 stakeholders 5 . The “Scene” is about setting the “vision” ( 65 ) and guidelines for good “preparation” ( 66 ) and “regime” ( 32 ) for managing the change. This step requires good coordination of expertise, resources, policies, and infrastructure, and their proper methodological assemblage with theories, concepts, and principles: we need a “global roadmap” of the case “problematization” and then possible avenues for operationalization ( 67 ).

Maps or “normative knowledge” of any kind (e.g., laws, techniques, standards, and treatments) must be designed in close collaboration with the people to whom the norms apply. Norms must be co-constructed, emerge from large social collectives, and be deliberated through an adaptive cycle of iteration. Normative thinking will lead to strategy (e.g., action plans), but must first (Step 1) build on ethical analysis. Strategic and ethical thinking must eventually hybridize into one process of reasoning through iterative deliberation and learning from feedback (Step 2).

Potter and Lisa ( 68 ) critic “sustainability” for being too strategic and not ethical enough, and highlights a way out through deliberation. Deliberation constitutes a large and every expanding methodological field of study in sociology ( 69 ), participatory research ( 70 ), management ( 71 ), governance ( 72 ), etc., that we must build on. However, as the “last step” (Step 3), ethical analysis is crucial for questioning the “terms and conditions of mandatories” over the programs or its actions before “re-proposing” (Step 1) for deliberation ( 6 , 66 ).

Collective Discussion

The collective discussion consists in bridging the general with the particular ( Figure 2 , Step 2). In particular, deliberation requires a systematic intake of credible information from the field , such as “consultations” and “interviews” could provide, which describes the community and its understanding of the change at stake. In that sense, deliberation needs to be data-driven , but not exclusively, because it must also be knowledge-driven by a process of transfer and “translation” ( 14 ). In general, the deliberation must be based on a vision of the change, like the one depicted in the “opening concertation” (Step 1) as well as transferable information from the academic literature.

The purpose of deliberation must be about governance: its architecture and future. For example, the case study began by deliberating on the form and content of the technology (2019–2020), then on the value of its SICT program and development (2021), and (to come) on norms for responsible conduct. Governance must be evaluated and deliberate at each “start” ( 72 ). This means building a dictionary from technological terminology to ethical meaning (Step 3). These last components of governance are immaterial but essential to envision a collective future ( 52 ). Meanings must be standardized (a dictionary), but also critical (reflexive governance) to learn and progress ( 36 ).

This mindset refers to system thinking ( 73 ). In practice, system thinking implies pursuing the deliberation process after the “end” of a specific mandate (iteration, Step n). The emerging vision and models provide insights for sharing the responsibilities, which means to learn and setting an ever better future —the scene (Step 1). For example, by laying the groundwork for a new proposal on the formal perspective of an Agreement in Principle for Responsible Animal Health Data Sharing (2021–2022). This Agreement must be initiated by design to acknowledge the “right” principle to apply for good collaborative governance ( 32 ) without delaying the speed of the change process ( 74 ).

Ethical Analysis

Ethical analysis, as a way to qualify the good and right “with discipline,” must be at each step of decision-making processes ( Figure 2 ). However, the disciplinary ethical analysis must be at the heart of governance programs (Step 3). Although ethical analysis must give the basic tone to reflexive balancing, reflexivity benefits from an abductive dialectic: to be tested by pair review, as a “discussion of multiple perspectives,” and case study, as seeking for a “consensual proposition.” In other words, reflexivity gains in value by the constant search for its democratization: aiming at spreading its methods, like critical thinking practices, and its result, the evaluated climate, resources, and capacities, in the case (Step 2). Moving from deliberation to the scale of a social phenomenon requires a solid reflexive “terrain,” as depicted in Paquet's work on collaborative governance ( 75 ). To emerge from various stakeholders, reflexivity needs an appropriate “Habitat” to express itself, such as research hubs, living labs, innovation hubs, or business incubators, among which Observatory on the Societal Impacts of AI and Digital Technologies (OBVIA) supports the development in the Québec public-private-academic “landscape.” To be inclusive, this process involved first defining problems collectively and deepening positions qualitatively (Step 2) but, therefore, an ethical analysis to progress this collective position (Step 3) considering social ethics, which “rules” may also need to be (re)set for a new “scene” in law, health, and technology (Step 1).

Ethical reflexivity is proactive in the manner of an adaptive and learning management process ( 76 ). In practice, the bioethicist's reflexivity and the team's expertise must be synchronized to scale up the (micro) personal insights to the (meso) collective, then (macro) social level ( 23 , 42 , 44 ). For instance, the bioethicist in this regard joins the FMVUM expert team which gives, therefore, a solid interdisciplinary ground to connect analytically with the social discourses in Québec animal health sectors. The bioethicist must shape and question the tools guiding the pragmatic negotiation toward an ethical (“pro” to “post”) position, without deciding himself the sense of that “final” positioning, which must rely on an ever-evolving collective ethic ( Figure 2 , Step 2) 6 . However, the collective position must take strength in the leadership of official entities (sponsors, e.g., government), but not rely on the “belle-parole” of consensus normative principles (see the distinction between normative and appreciative knowledge in the last section). The leadership of the team in charge is based on two justifications (Step n). In the short term, this justification takes its strength from the political legitimacy, for instance, the Government of Québec's GPHP statement: through the periodic renewal of the “terms and conditions” by financial, regulatory, or declarative means. In the long term, this justification becomes powerful, however, this appreciative “parole” depicts an acceptable future having the capacity to impel a culture of empowerment ( 6 ).

Iterative Process

Ethical analyzes understood as ongoing critical thinking processes are a key functioning characteristic of reflexive governance. The ethical analysis aimed to criticize and give purpose to:

• Strategic plans [feasibility and acceptability ( 78 )] developed collectively to negotiate social discourses ( 58 ).
• Decision-making processes conduct at multiple scales—the expert, the team leading the project, and representatives (e.g., sponsors, group leaders)—as they choose what best insights are meant for the community and about the future of society.

For example, One Health's scientific questioning is about how to develop a strategic (feasible vs. acceptable), judicious (risk vs. advantage), and responsible (short vs. long-term accountability) surveillance program for antimicrobial use. Conceptual roadmaps are useful to nuance and negotiate the positions of the various stakeholders (i.e., perspectives, roles, and missions) about the meaning of what is good , to move toward a consensual justification and thus binding decisions. The usefulness of such tools is not in their mapping of social system complexity ( 79 , 80 ), but in mapping the system of values, interests, and perceptions ( 81 , 82 ). A mapping of ethical frameworks and normative theories is crucial for the ongoing questioning about possible biases and finding ways to manage these appropriately when and where they arise.

When assembled with bioethical methodologies or approaches to guide the bioethicist in the use of theories in practices, deliberative maps (as the one depicted above) became pragmatic analytical “tools” and could support professionals or other actors in their day-to-day decision-making. These hybrid tools can be designed for individual or collective use. These tools focus on structuring critical reasoning to get through complicated choices; they aim to identify, nuance, and contextualize tensions that transcend the decision-maker. These tools can also be seen as evolving roadmaps of the One Health paradigm and an advance in applied ethics (such a tool is proposed in the last section). When applied to a case, these roadmaps emerge from a confluence of expert and community perspectives as both have relevant viewpoints. However, roadmaps should evolve based on experience, not mere intuition. Real-world feedback is a core asset for the ongoing process of reassembling what is collectively conceived as a good change supported by intelligible methods from the field perspective.

Applied to the case of a feasibility study in veterinary public health, in Québec, Canada, we will see how methodological innovations are implemented by people, institutions, and theories in constant evolution: a complex that “weaves together” three dimensions of “global” existence (structural, cultural, and intellectual) that we have called “community” above ( 6 , 15 ). This sociological perspective on the organization of science in society clarifies that there is no new generation of “social” but always new forms of reassembled structures, functioning, and/or purposes ( 16 ). This communitarian perspective means that much of the power is distributed in the social (of which people are the elementary unit and society is the overall organization) than what would appear to be the case under a centralized or even hierarchical understanding of authority ( 22 ). Answers to the question “how do we democratize deliberation” must find clues in “how the social “perceives” its own normative theory” in a case study: the “collective ethics.”

Learnings From Sustainability

A commonly used ethical tool for bridging reflexivity and deliberation in the field of animal health and environmental risk management is to refer to the pillars of sustainable development which, by their interface, bring out a set of values as emerging fields of study: viability, livability , and equity . These fields act as a driving force for interdisciplinarity, notably political economy and ecology ( 83 ). However, many scholars have criticized and advanced this approach, and from which One Health should learn ( 52 , 62 , 68 , 84 ). For example, sustainable development aims to manage—i.e., (re)maps, (re)frame, and (re)shape—based on an ongoing process of balancing the value of short vs. long-term goals ( 26 ), such as mitigating the overall risk of resistance, with its short-term goals of health care services for local communities with antimicrobial governance norms ( 6 ). The sustainable analysis could become a tool to examine feasibility studies and manage its related ethical dilemma, for instance, short vs. long-term and private vs. common considerations. Even, it could be useful if it means degrowth as not-developing pharmaceutical or reduce the use—i.e., a reframing for global acceptability as a Potterian's socio-ecological concept ( Figure 3 ).

Responsible conduct for governing sustainable technosocial development [see Potter ( 6 )].

The real world is also much more complex than these three pillars and values of sustainability, because the observer evolves, learns, and “thinks [s] in systems” ( 73 ). Norton, who works on the “philosophy of sustainability,” explained good development might be rooted instead in a “localism, experimentalism, and multiscale analysis” approach ( 52 ). Norton's understanding of sustainability allows for organizational resilience built on adaptive agility of collective policies: the adaptative management ( 85 ), allowing for several scales of observation, here the bioethicist, the FMVUM expert team, and the community as a whole ( 86 ). This learning ability is based on a functioning cycle: reflexivity, deliberation, decision, and evaluation. By reconnecting the cognitive and social spheres by introducing a multidisciplinary team at their interface called “Frontrunner,” Loorbach lays the foundation for an alternative model of governance that decentralizes this four-step thinking process within the network. Frontrunner's goal is to guide the transition management, notably toward sustainability and stakeholders' empowerment, for instance, about their digital environment, responsible conduct, and norms of practice on antibiotic use. Managing here means “reassembling” the decision-making process to clarify who decides, even more, who is accountable and expected to justify; and who evaluates, that is, who provides feedback, including useful learnings to improve programs and actions ( 87 ). “Reassembling” implies a dynamic planning process well before a crisis occurs, in order to quickly involve actors with short notice to “reorganize” in (infra)structure and culture ( 16 ). To implement these new sociological models with systematized methods, we also need to use collaborative ethics ( 36 , 88 ).

Learnings From Governance Systems and Community

Community-based approaches refer to collaborative and learning mechanisms: Let us propose the idea of an “adaptive co-management of transitions.” Collaborative thinking is facilitated by systems of information and communication technologies (SICT) that scale data sharing to knowledge transfer, translation, and applications. The philosophy advanced in the case study was based on learning: antibiotic use surveillance supporting both national antimicrobial governance policies through public reporting and refining individual conduct through voluntary benchmarking.

Although there have been technical advances with SICT, an ongoing challenge in ethics remains to bridge the gap between experts and the community. A possible solution lies in critical deliberation and evaluation ( 89 ). Along this line of thought, Rüegg et al. ( 63 ) present an approach to collectively plan and evaluate sustainable health interventions by thinking beyond the frame to working on a strategy to support convergence and make change happen. In alignment with this perspective, Bordier et al. ( 90 ) assess the methodological and epistemological challenges behind the evaluation of knowledge emerging from “multisectoral collaboration” through “interdisciplinary insights” ( 91 , 92 ). Multisectoral collaboration needs to be evaluated, notably with a focus on the performance of the surveillance process ( 4 ), on its systemic process of sharing information ( 91 ), and on the consequences of the resulting policy ( 36 ). However, one of the most challenging aspects to evaluate is certainly the value, the credibility, and the validity of One Health knowledge and policies across different domains at the time of its justification to accelerate its application ( 18 , 23 ). Some answers may be found in pragmatism and how the community can learn.

To ease the functioning of SICT, one of the upstream goals must be to develop a common consensual language that puts everyone “around the table” on the same “terms” (terminological and ontological). “Language” here means helping each person or group to move beyond their position and broaden their perspective to a collective reference point (epistemologically and teleologically). “Common” means a collective assemblage, joined under one “roof,” in constant “recruitment” of social actors, diverse (axiologically) in problems, abilities, and ideas, but all interested in managing the same “problem” ( 14 ). The case study bridges the emerging collective ethics of stakeholders and the social ethics emerging of collaborative governance theories ( 32 , 72 , 75 ) by deliberating on an Agreement for Responsible Animal Health Data Sharing. Governance is about administrative and political structures but also goes beyond this, as a regime and vision whose rudiments must be materialized in intelligible documents accessible to all, such as an agreement, charter, declaration, code, etc.

The case study highlighted the challenge of transforming a collaborative regime (as a philosophical theory) into a governance body (administrative practices) whose functioning is acceptable for stakeholders—i.e., justified by collaborative ethics—and still meets the expectations of sponsors, mandatories, and society ( 34 ). The solution found was in iterative processes: collective ethics and governance regime must emerge from an adaptive cycle of ethical decision-making processes and from empowering leadership materializing the process in action ( Figure 2 ). This new cycle (proposed for 2022) will involve the signature of that Agreement, which will “shape” the development of the data platform. To ensure the trust of stakeholders from the start to the end of the biosurveillance programs, which will evolve to expand data input across sectors and the overall outcomes of aiming to implement the One Health perspective, the Agreed Principles must progress as well (post-2023).

As Abma et al. ( 42 ) outlined, bioethicists are key assets to co-evolving practices, as “inter-ethics” (for proactive and interdependent) bridging the gap between the leadership team and the community. Inter-ethics opens deliberation on the (intern) program and (extern) partnership policies and values. Bioethicists are key to the functioning of large organizations such as companies, research groups, and public services. The functioning transcends (as singular) the ability to foresee a decision-maker, as the Chief executive officer (CEO), even the Chief information officer (CIO). Hermeneutic approaches, such as the maieutic process of Socratic dialogue ( 93 ), or others from applied ethics, such as casuistry (case study), should be implemented as a day-to-day approach for improving the critical thinking practice (as singular: CEO and CIO), even allowing for collective and deepen deliberative reasoning ( 58 ). The bioethicist leading these ethical approaches should not shape the problem in practice ( 94 ), but support the process of intellectual mapping and interdisciplinary framing ( 26 ) to help stakeholders design and manage their ethical shaping process ( 40 ).

The role of the bioethicist is to provide an adequate habitat for collectively “thinking global,” not to prescribe global thoughts ( 23 , 42 , 44 ). As illustrated by John Godfrey Saxe's (1816–1887) “The Blind Men and the Elephant:”

And so these men of Indostan

Disputed loud and long,

Each in his own opinion

Exceeding stiff and strong,

Though each was partly in the right

And all were in the wrong!

The main criticism of global thinking, as here depicted in terms of communitarian approaches with the “elephant,” is about the sense of urgency: Is their time for this discussion between “Indostan”? Antimicrobial use calls for rapid and radical change, yet incompatible with cultural changes requiring long-term collaborative, democratic, and reflexive processes. In the animal health sector, urgent and radical change means the commitment of stakeholders who are complexly organized as shown by Majowicz et al. ( 79 , 80 ). Moreover, long-term collaborative processes mean reconciling a diverse system of deeply distinct ethical values ( 45 ), notably the views of the agri-food industry vs. vegan activists, or even traditional indigenous knowledge ( 34 , 95 , 96 ). The case study shows that co-building a collective ethic tends to accelerate the commitment of stakeholders by linking their actions to an awareness of the consequences, which leads them toward a culture of change. Collaborative governance, here defined as a state of mind ( 72 , 75 ), even a community-based approach ( 97 ) or a communitarian paradigm ( 22 ) rather than an (administrative) governing body, accelerates this cultural bridge to the future ( 5 ). However, to be collaborative, governance must also acknowledge specific and generic concerns: sometimes even questioning collective paths in the face of local issues (bottom-up) or front of societal values (top-down). This abductive process (“local-to/from-global”) necessitates the integration of top-down (e.g., government to citizens) and bottom-up (e.g., citizen to government) modes of governance.

Learnings From Pragmatism

The case study was built on a pragmatic approach to ethics. Whereas, the good relies on imperatives (yes/no answers) in a deontological or legal perspective, the pragmatic ethics approach shifts the emphasis from the “imperative” to a deeper collective deliberation process that democratizes thinking about such ethical criteria as good, right , and better . Pragmatic ethics recommend, first of all, putting aside the prioritization of which is “right” or “wrong” between scientific, traditional, and alternative knowledge and beliefs ( 87 ). The priority is to act on tipping points, such as the need for surveillance of antibiotic use and thus for the governance of its SICT to refine practice, by seeking consensus between the parties involved on how to do it ethically ( 18 ). In practice, Callon ( 98 ) named these as points/nodes of common problematization and explained how convergent perspectives and interests stimulate the recruitment of ever-increasing numbers of actors around the common problem to solve. This is about assigning duties for what and to whom, i.e., the “pragmatic sharing of responsibilities.” Moreover, responsibility is linked to resources, so deliberations must focus on the actor's duties, assumptions, and capabilities: does each stakeholder have the necessary resources, opportunities, networks, technical abilities, theories, or other necessary “tools” to achieve their goal (their responsible mission)? In the case study, all the actors involved—industry, activists, and researchers—agreed on the importance of solving the antimicrobial resistance problem, even if it was for different reasons, and to archive this collective position in an Agreement, whose principles would detail these contextualized duties. Under this pragmatic view, the core problem was no longer the “Why” to act, but the “How” to interest all stakeholders to act collectively and in concerted fashion, i.e., the “common problematization.” This led us to apply ethics and its rationale to share responsibilities appropriately (e.g., duty, ability, and capacity to act) among the key stakeholders.

One of the core challenges of One Health is to operationalize pragmatic processes (the “how-s”) and build consensus for action. Indeed, some deontological positions are inevitable (the “why-s”) and create conflictual ethical points of view ( 18 ): Who should be responsible? Which core values to prioritize? Is it for the benefit of humans (anthropocentrism), all living beings (biocentrism), or communities (ecocentrism) that we should act? Mermet's work on social negotiation ( 58 , 69 ) can help bridge the gap between Social and one's thinking . Designed for strategic analysis, social negotiation can provide pertinent tools to bring into practice Latour's framework [see Bilodeau and Potvin ( 99 ) in public health].

However, strategic analysis is a “descriptive to normative” knowledge translation process. This translation must be combined with an ethical analysis to prevent fallacies. For example, medical diagnosis (prescriptive) must be based on history and Biology (descriptive), but overall, the transition from one to the prescription of a particular treatment (an antibiotic) must be based on the clinical judgment of the physicist. The action-ethics framework presented here proposes such a “descriptive/appreciative-to-normative” knowledge translation process applied to political processes. Defining the right course of action, meaning the “justify normative knowledge” that will lead to responsible actions, requires the involvement of many people from various disciplines. Appreciative knowledge is the key to expanding the perspective, for example, the Government of Canada's Categorization of Antimicrobial Drugs Based on Importance in Human Medicine, which is normative, seeks to prevent harm by adding such antimicrobial governance insights to medical practice. The “inter” of the “interdisciplinary” is about quality: Who or what is bridging? Too often, the “appreciative” fields of knowledge, carried by the humanities or the human sciences, are underrepresented. Co-building collective ethics as a structuring process of a One Health transdisciplinary program will help to highlight, “in action,” those missing pieces for normative practices.

An important criticism of pragmatism has to do with relativism. Who actually decides what is right after all? Notably about data access or even antimicrobial governance. Is it the Law, the people, the market, the activists…? In terms of relativism, these dimensions—legal, civil, financial, associative—pose “truths” of equal importance. Pragmatism in ethics does not, in any way, reject the importance of deep debates, nor the negotiation of these dimensions, or the radical questioning of the way things are done ( 18 ). Pragmatism cannot be achieved without these in-depth reflections to define broadly which better future we want to achieve collectively ( 5 ). Therefore, pragmatism is more about deliberation than decision, even more about education than action. However, the main characteristic of pragmatism is, indeed, action-oriented: deliberation and education process must lead to tangible, practicable, and (if well-done) prospective knowledge—such as collective vision and goal. Such an objective for discussion leads to determining agreeable points to act at a specific time and place and acknowledging a need for an ongoing process of evaluating, criticizing, and adapting those pathways of action. These enable progress for/by the community while recognizing potential harms to individuals and the environment (suffering, vulnerability, and existence). Giving credit to the community, pragmatism justifies having representatives (as an expert or social voice) capable of deepening and raising positions anchored in complicated scientific phenomena and complex system values.

To know who decides, the question should be: “Who is the most credible to carry out the collective work of deliberation?” and more importantly, “Who is responsible for it?” The case study showed that multidisciplinary teams mandated by public authorities can become key actors to structure transdisciplinary projects—a Transprogram —as a “flying team” in the collective creating a dynamic bridge between the expert and the whole ( 46 ). The team becomes a binding, critical, and justifying force: public values (democratic government), academic knowledge (“balanced” expertise), and a “targeted” community. A “transprogram”—a neologism that implies a “transdisciplinary” in action ( 56 , 89 )—can be conceived as a continuous process of knowledge building and collaborative governance ( 16 ). This forces us to complexify our understanding of the “theory to practice” challenge. It is not simply a question of bringing knowledge to action through “communities of practice” or other forms of collective ( 100 , 101 ). It necessitates theoreticians (e.g., philosophers and mathematicians) develop the “practitioner” reflexivity personified by in situ questioning of what we must do as a person and how to empower such critical thinking.

We need to organize what we—as a collective—are saying. Transdisciplinary—as the increasing relationship between sciences, technology (e.g., the industrial products), and society—introduces a confusing mess of terminologies, methodologies, and philosophies that must proceed throughout the program (as political, scientific, and societal) development. At a minimum, proceeding with this “mess” in practice requires ethics: critical thinking, codes of conduct, and responsible organizations for an ever-learning process in ethics. Extended to society, a postnormal philosophy of sciences ( 56 ) proposes new models that recognize the value of falsification ( 102 ), but extend the theory about the Structure of Scientific Revolutions ( 103 ) to include new tools from sociology, anthropology, and technology emerging from the digital age ( 74 , 104 ). As presented in Figure 2 , program development must return to the scale of people (theoretician, practitioner, “fieldworkers” and representatives) but be institutionalized as a democratized deliberation process. The challenges of such collaborative governance ( 72 ) and transdisciplinary research ( 105 ) are to be contextualized in a constantly changing world without losing the local perspective as developed in Morin's complexity paradigm (see the synthetic tool in the next section).

A pragmatic bioethics approach will be crucial to achieving this goal. To seek precision, the sciences tend to fall into the specialization process (disciplines and techniques) and lose the “big picture” as Saxe ( 106 ) has noted. On the other hand, philosophical reasoning, methods, and theories in ethics may lack an operational strategy for seeking and driving empirical and practical change toward empowerment and political sharing of responsibilities. Both aspects need to be integrated into an interdisciplinary process to proceed to a sustainable course of action, and this is where bioethics can step in ( 107 ), to act as a translation mechanism, and so become the missing link to materialize interdependency ( 37 ) without resorting to disciplinary reductionism ( 108 ).

How can we seek Global acceptability? How can we mobilize science paradigms to set a “feasible” normative theory leading to a co-built code of ethics for empowering the community? ( 6 ) Shaping ethical tools, such as codes, methodologies, and education resources, are core assets for sustainability because they pave the way to basing its operation (the result of integrating the three pillars) on values (e.g., its equity, liveability, and viability): each action must be rooted in in-depth justifications (the values) bridging sciences and ethics ( 5 ). One Health benefits from such tools, here called “bioethical” referring to this Potterian “bridge,” in the format of reflexive, deliberative, and evaluative practices. The bioethical tool below contributes to deepening methodological reasoning to guide toward more practical pillars, but still rooted these in the core values of sustainability ( Figure 4 ).

Framework to broaden critical thinking used in the case study to building reflexive governance: A bioethical tool, “mapping” One Health methodologies and teleologies, to help in “framing” and “shaping” the work to deepen the meaning of persons, groups, and the community reasoning to broaden the collective perspective and co-build a global vision, but still locally collaborative, of One Health governance programs. Designed in empirical bioethics by case study approach, in the Quebec animal health community, the one emerging from the commonly shared One Health problematization of antibiotics (production, use, and resistance) linking Government Ministries with shared jurisdiction over animals, human, and environmental health, this tool seeks to broaden the critical thinking of the expert training in bioethics, the coordinating team members with leadership, and stakeholders. Constructed by abduction based on the revised theories and the case study depicted as a community-organization that evolved its practice. This tool must guide the reflexivity of each person at each of these collective discussion steps.

Broadening the vision in Saxe's poem means being more integrative, even appreciative. These levels of knowledge are about building consensus and deepening the reasoning of each stakeholder from their own point of observation to define the problem and interest in its resolution. A vision of change must transcend all dimensions of existence to question fallacious reasoning all along with the life of the surveillance program coming from integrating levels and points ( 26 , 42 , 44 , 105 ).

Figure 4 proposes three practical questions at each interdependent interface—(1) evaluation, (2) reflexivity, (3) deliberation—to share responsibility and “take a position.” First, “plan the right positions to see,” as an evaluator , in terms of infrastructure and paradigm, and then “coordinate the scene and assemble collaborations from these positions” and diverse knowledge (several perspectives per level). For example, to see and coordinate, search for, or create a governance body with authority over financial planning, institutional sustainability, and stakeholder accountability ( 36 ). Collaborative governance increases credibility and trust ( 32 ), especially when the partnership that embodies this governance diversifies the collaborators. Then clarifying the rules of the game facilitates comanaging the empowerment process in terms of “adaptive governance systems” through deliberative processes. Taking a position means balancing knowledge from experts and value from sponsors [formal and informal terms and conditions ( 23 )]. Note that (e)valuation is a continuous ethical-scientific process that must be pursued throughout and collectively on as many sub-dimensions as possible, and involves balancing the three identified here for a valid (pro/post)position (green) and the trans-level of knowledge (red) in time and in forms that support decision-making.

Evaluation ( 1 ) should be a continuous process, as the concept of surveillance and program evaluation understand it, but also includes the observers as a thinking unit to study the impact of the technosocial initiative and its policies. Observations should be planned upstream, based on both understanding and vision, to locate the evaluating -observer in an ethical and strategic place to see. Vision means a roadmap of what is foreseen as good , envisioning a better future . Maps are factual models built on-premises (values). Deliberation ( 3 ) as a social negotiation process is crucial to translate knowledge, vision, and values into policies. Deliberation implies negotiating the interests of the parts, judging actions, norms, and singular values in front of the common interests. Reflexivity ( 2 ) is the solution to an ethical, pragmatic negotiation.

The bioethical tool ( Figure 4 ) integrates the three pillars to “Thinking Global” (existence, knowledge, and observation: Table 1 ) describing the intellectual world in which evaluative and deliberative decisions must be made:

Reflexive aspects to think “Global” about, before and while planning and deliberating on the surveillance program a .

• Dimensions of existence (the empirical): the experience of life as a person and as a collective (family, society, and humanity) whose experience and context become accessible from the attentive “eye” and reflective strategies conducted in a community as a space/time, transgenerational and multispecies concept ( 22 )—“What exists?”
• Levels of knowledge (the cultural): sophisticated tools ranging from technologies to theories helping to deepen reasoning, to justify decision-making, or directly to change the conditions of existence—“What should it be?”
• Points of observation (the intellectual): the intellectual lenses leading to subjective action of the expert and from the community (as thinking units, not things) to assess the effects of decisions on several patterns and scales—“What do we want to do?” “What could it be?” and “How will it be done?”

The Dimensions of Existence

The bioethical tool ( Figure 4 ) extends the scientific perspectives of “experiencing” the existence —the observable (objective) and the being (subjective). Physics, for instance, is not only a scientific discipline but also a dimension of existence ( 15 ). As a knowledge, Physics describes the complexity of the physical world (from the Greek “physis” means nature); thus, giving physicomathematical architecture to science paradigms toward natural laws, notably in chemistry, biology, pharmacy, and also engineering, medicine, management, and any kind of evaluation techniques on antibiotics or environment ( 110 ). As a dimension, Physical is about space and time from which empirical phenomena emerge; thus, providing (predictive or reflexive) insights—the pharmacokinetics of antibiotics, the probabilities of resistance genes, the microbial ecology studying natural evolution, and ecotoxicological geography of heavy metals ( 111 ).

Physics, commonly referred to as objective, natural or factual understandings, is one of the fields of descriptive knowledge , but the “empirical” is also about the collective existence in that physical world, involving norms and standards. Some normative knowledge is based on the empirical description: when observations become physical laws through experiments or even when these laws are translated into strategies, techniques, and technologies through the lens of understandings and values, for example, a standard based on the “ecosystem services” or “footprint” communication tool ( 112 ). Although mechanical laws and probabilistic models translate the physics of the world into understandable terms and tools, it does not mean that the whole physical world is, at some point, entirely understandable or even partially controllable (the positivist fallacy), especially when it is necessary to cross dimensions (the Morin bio-socio-anthropological model ), such as the psychology of antibiotic users and the ecology of antimicrobial components. Recognizing this fallacy, descriptive knowledge must not prescribe actions on its own—e.g., the statement: “This antibiotic will cure that disease”—without being understood through the lens of scientificness (e.g., validity) and as human power and will, interwoven with belief and values, and embedded in conflicting interests and missions ( 45 , 56 , 87 ).

Alongside Physics , several other dimensions make it possible to analyze humans within their own existence : the Social and Anthropological dimensions of life. As for Physics vs. Physical , all those 3 dimensions are related to knowledge, among others, in psychology, ethnology, and axiology, which gives us access to its perspective. From those perspectives, we—as humans and humanity—experiment by observing and being: the dualistic (objective vs. subjective) experience of life ( 113 ). The need for both Object and Subject perspectives explains the usefulness of integrating natural, social, and human sciences. Subjectivity , to be understood here as reflexivity , brings the missing piece to positivism: the so-called postpositivism. Values, the missing piece, respond to uncertainty ( 56 ). For instance, political decisions on antimicrobial use and the progress of science in pharmacology and ecology must be proactive and responsible (the precautionary principle), despite there being no evidence (at least yet) on all the mechanisms of antimicrobial resistance, nor a full understanding of microbial evolution ( 1 ).

The challenge is to “Think global”: How to integrate all these dimensions, acknowledging the pluralism of perspectives and values? Moreover, how to progress decision-making with critical reflexivity, but without rhetorical fallacy? The answer points toward deliberation and evaluation to deepen everyone's positioning. This process must emerge from science and society (e.g., the Intergovernmental Panel on Climate Change, IPCC, or any public hearings, association, or platforms) as a community-based action-ethics methodology, although they will for this bridging process is not a given at the start.

Levels of Knowledge

Decisions are fundamentally subjective, because humans—expert and non-expert—are beings, not things, and think. Thus, some knowledge is more likely to change, while others are more stable over time ( 23 ). For example, the former refers to medical diagnostics ( appreciative ) and State laws ( normative ), while the latter refers to scientific observations ( descriptive ) such as those of physics ( 105 ). The speed of light and the gravitational constant are given ( fact ), while policies and diagnostics can change, and even less stable are the beliefs ( opinion ). These levels of knowledge , its strength, and even possible progression are not really messy but require an ongoing process of communication, management, questioning, and transparency to avoid fallacies ( 114 ). However, normative knowledge is a broad area. The decision leads to such knowledge: norms are about the Act, Vote , or any techniques archiving someone decision, which systematized action. For example, legal laws are normative as well as government, industry, and academic programs operating in the technology and, more broadly, into the social . Decisions—and the following actions—must always be studied, evaluated, and reframed collectively to progress these norms 7 . Progress is driven by examining the criteria and quality of its justifications (validity, credibility, integrity, etc.): the value of ideas and advances. These values become shared appreciative knowledge under community-based ethical analysis, which integrates academic, political, and civil perspectives as Global evaluative insights ( 16 ). The justified decision is about “responsible conduct” and “social responsibility” at the actor and network level, and should not be based on a decontextualized singular interest or ideology ( 5 , 115 ). Democratizing governance processes through education and promotion refers to pragmatism or “collaborative governance,” and operates through communication, open dialogues, and constructive criticism on the justificatory and uncertainty value of programs ( 72 ), but implementing large-scale evaluative, deliberative, and reflexive practices remains, indeed, a challenge. Avenues for action have been highlighted here, including the organizational dynamics emerging from an Agreement hosted by a collaborative governance body and evaluated by a Living lab.

Good decisions and norms, which means being shaped by ethics, require more than being fact-driven or value-driven —they need both. This requires deepening the thinking process to “transcend” all levels of knowledge ( 105 ), that is, to bridge the descriptive and appreciative knowledge , as the Québec Agri-Food AI Ateliers has been a successful example ( 46 ). “Transdisciplinarity” implies going beyond statistical, mathematical, or predictive data-driven reasoning to interpret data and models ethically, as appears to be a priori monitoring of antibiotic use and a posteriori the translation of surveillance insights into antimicrobial governance policies. Classical scientific methods (positivism) are valid when framed by models or conducted within controlled environments, but fail in the real world, notably the ecological ( in situ ) surveillance of antimicrobial resistance ( 111 ). This issue opens room for reflexivity and deliberation in research (as action-research ), but also more broadly in society (as action-ethics ), requiring educational tools to operate: the example of the antimicrobial footprint ( 112 , 116 ), which integrates learnings and competencies from history and art (see Saxe's poem, above). Hard decisions about human life, environmental crises, and next-generation implications need to be “based on ethical values, which are in the long run inseparable from scientific facts” (paraphrasing Potter's maxim). This intellectual agility requires transparency to challenge justifications prior to undesirable events. Seeking transparency must be a constant and proactive quest, becoming even the core (functioning) aspect of collective ethics leading to the emergence of empowerment practice. Although conceiving how to manage and acknowledging what such transparency might be complicated to assess, deliberation points to possible paths for action.

Points of Observation

One of the main aspects to be considered goes beyond knowledge and existence and enters the area of actions. This perspective, or point locating the observer in action in the world, refers to a “bridge to the future” ( 5 ) and is about “human responsibility” ( 117 ). The positioning, as the inspector, researcher, decision-maker, or even public health policy perspective, is in constant dialectic with (influencing it and biased by) its contextualizing system ( 73 ). Indeed, “Ethical values [the positioning] cannot be separated from biological facts” ( 6 ), meaning the surrounding ecology and economy of antimicrobial resistance to the inner psychology of behaviors and will of antibiotic users and decision-makers. Ethical values are an articulation of the (free) will to change. A will for change must emerge from the case ( in situ ) through convergence with applied sciences and practices, as initiated in One Health and sustainable development. Theories remain crucial to understanding what is observed, e.g., through the anthropological (belief, family, history), the sociological (institutional power and knowledge dynamics), and the biological (e.g., organisms and organizations).

How can we manage to Think globally while acting locally , as individuals within the (social) collective, (biotic) community, even (planetary) ecosystems? How do we evaluate locally (for us) while deciding globally (for all)? How do we do planning (long-term) while implementing (short-term)? How do we regulate (decide) while questioning the norms, guidelines, and understanding that have been established? ( 6 ) These questions find some solutions under the theoretical frameworks of “thinking in systems” ( 73 ) and mathematical scales ( 118 ) as “coadaptive management” and “adaptive governance” processes ( 77 ) and under more applied frameworks such as in “transition management” ( 74 ) about governance bodies and socio-ecological systems.

Deliberation is linked to the growing interest to find ways to integrate experts, traditional, citizens or, even alternative knowledge ( 71 , 113 ). However, this should not reduce the value of scientific knowledge, but rather enrich it; these different types of knowledge (expert and non-expert) have different functions in the construction of human narratives. While expert knowledge seeks disciplines (laws, principles, mechanisms, and measures), other forms of knowledge express values, cultures, and beliefs. The latter communicates the realities of humans, beings, and things in various ways. Acknowledging the pluralism of values, as the appreciative knowledge of a collective, is a driving force (the free-will-power) for empowerment. These values can justify action before crises, i.e., to set in action the whole “scene” ( Figure 2 ) to build the resilience of the system. In short, the will of a government or single decision-maker is insufficient to encapsulate the will of all ( 14 ): we need ethics (codes, methods, and prospectives) to empower each one to collective changes with a roadmap and a compass in order to navigate between different wills and aim at the common project ( 119 ). However, as an opening, this code must progress and go through an iterative phase of questioning ( Figure 1 ).

This paper seeks to lay the foundations for a methodological framework in empirical bioethics. Instead of focusing on ethical theories in philosophy or sciences, we reviewed the methodological literature in empirical bioethics, One Health and Sustainable Development study to lay foundations in pragmatism (J Dewey)—( descriptive ) pathways to operate instead of ( appreciative ) guidelines to dictate ( normative knowledge ). The ultimate goal was to support the actual will in those fields of study to build reflexive governance, notably in One Health, to address the issues concerning the pharmaceutical agents necessary for medical practice (the antibiotic cure), but modifying the environmental conditions (the problem of antibiotic resistance).

To bridge the gap between person-to-person dialogues and social negotiation processes, the operational pathway goes through comanagement techniques and must target cooperation nodes. Notably, the manager must bridge the gap between the construction of the Social (its ethical narrative) and collective practices, which leads to empowerment ethics. This operation translates the adaptive governance cycle into a new ethical technique of “R&D”: Project management in Research & Development , the one that confines them into two parts, must shift to a more integrative practice, called here the adaptive Reflective-Evaluative-Deliberative cycle. These communications and knowledge systems open to a perspective bridging the biological, social, and intellectual Latourian's collective and biotic community concepts to responsibilize the former over the latter.

As shown in the case study on an antibiotic use surveillance program in animal health, being prepared means being empowered and responsible, which facilitates stakeholder engagement and even promotes collaborative nodes to accelerate changes. Preparation means joining the community-based action - ethics methodology to R&D practice from the start: at the time of policy (see: GPHP), program [see: ( 46 )], and project (see: FMVUM team) ideation. Acknowledging ethics shows ways to share responsibilities among stakeholders to empower each in their respective competence for action. Empowerment ethics deepen the meaning of responsibility. Being responsible is more than accountability, it is linked to duty, proactive transparency, and scientificness as credibility and validity. Empowerment implies finding ways of acknowledging the respective position of stakeholders, notably roles, interests, missions, observations, and values, to respectfully manage multi-actor systems and share responsibility toward successful and ethical changes.

The ethical conflicts between the cognitive and the collective—as the singular will and common good—can only be managed through an open dialogue that continuously seeks ever better solutions, as more accuracy and consensuality. Thus, instead of questioning how to access data as a justified end 8 to solve the antibiotic resistance problem or other One Health problems, we should look to empower the community to manage their data (a fairness Open data approach per community). The question we should be asking, then, is: How should we manage an Open dialogue between data producers and users within the community to start local changes? With empowerment ethics focusing on transparency, translation, negotiation, and arbitration, what we should call reflexive governance , we can engage groups and collectively drive cultural change and the willingness to accelerate it (an Openness to data ), and then connect communities (human, animal, and ecosystem health) to reach the broader perspective of One Health and the Sustainable development of its programs, even its paradigm.

Data Availability Statement

Author contributions.

AB was responsible for the conception and ideas presented in this article, contributed to the planning, and conduct of the qualitative survey described in the article as a case study. CA and BW-J reviewed the initial manuscript, contributed to the text through changes to structure and addition of new content, and approved the final manuscript. All authors contributed to the article and approved the submitted version.

This article was supported by funding (Ph.D. scholarships) from the Institut de Valorisation des DOnnées (IVADO), the Global One Health Network (G1HN), Centre de Recherche en Santé Public (CReSP) and the International Observatory on the Societal Impacts of AI and Digital Technologies (OBVIA). The corresponding author was an employee of the Faculté de Médecine Vétériaire at the Université de Montréal, hired to accompany the feasibility study on the implementation of a monitoring system for antibiotic use in veterinary medicine in Quebec by the Center for Expertise and Clinical Research in Animal Health and Welfare (CERCL) mandated by the Ministère de l'Agriculture, des Pêcheries et de l'Alimentation du Québec (MAPAQ).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

The authors recognize the important contributions of the team leading the feasibility study of monitoring antibiotic use, and all those who participated in this collective brainstorming process, especially Ferrouillet, Laroche, and DesCôteaux, in organizing the deliberations, and the Government of Québec Ministère de l'Agriculture, des Pêcheries et de l'Alimentation (MAPAQ). Affiliated with Groupe de Recherche en Épidémiologie des Zoonoses et Santé Publique (GREZOSP), Centre de Recherche en Santé Publique (CReSP) and Observatoire Internationale sur les Impacts Sociétaux de l'IA et du Numérique (OBVIA), the author was able to benefit from rich discussions with members of these communities who contributed to the reflections presented here.

1 Abduction and inquiry (a “top-down / bottom-up” approach) are key processes from pragmatism (C. S. Peirce 1839–1914 and J. Dewey 1859–1952) to bridge behaviors, norms, and beliefs, but requires ethics to function properly ( 8 ).

2 For instance, the Stratégie québécoise de santé et de bien-être des animaux proposed an antimicrobial governance plan for all veterinary practices, the Comité consultatif sur l'utilisation judicieuse des médicaments for the pork industry and the professional Order as well as academic institution as initiated their own reflection. Each act on different domains (veterinary sectors), scales (professional advice up to national policies), and levels (from descriptive data to prescriptive commend or evaluative thinking).

3 Depending on his·er background, the bioethicist can also reinforce networking, designing, applying, and synthesizing. As illustrated by the idea of “living labs” put forward by the International OBVIA, a living lab applied to bioethics can help manage power relationships, mainly those driven by interests and values ( 45 ), from an understanding of responsible conduct procedures and ethics in academic and governmental researches.

4 See the Agri-Food AI Ateliers initiative ( 46 ) or Montréal Declaration for a Responsible Development of Artificial Intelligence deliverative processes ( 47 ).

5 Note an ever-increasing recruitment process, involving 100 actors in 2020, to seek saturation of the perspectives, and continue the incentive process (the “interessement” according to the Latourian perspective).

6 “Final positioning” does not exist within a collaborative governance depicted as an adaptive cycle (Step n). (Pro/post)position refers to the adaptative cycle in management ( 77 ) which must become a “constructive” and not a “disruptive” process.

7 Economics, literally the rules of the house (“Okios nomos”), should join the projects in sustainable development with this general sense.

8 For example, are the FAIR Guiding Principles a means or an end? ( 120 ). As a means, they respond to the criticisms leveled at the Open Data movement , when perceived as seeking “open bars.” We need the complement of a FAIRness ethic to frame responsible data sharing.

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• Fostering relational autonomy in end-of-life care: a procedural approach and three-dimensional decision-making model
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• http://orcid.org/0009-0000-7846-7784 Kar-Fai Foo 1 ,
• http://orcid.org/0000-0002-5992-2144 Ya-Ping Lin 1 , 2 ,
• http://orcid.org/0000-0001-5810-8776 Cheng-Pei Lin 3 , 4 ,
• http://orcid.org/0000-0001-7234-4484 Yu-Chun Chen 5
• 1 Institute of Public Health , National Yang Ming Chiao Tung University , Taipei , Taiwan
• 2 Department of Medical Humanities and Education , School of Medicine, National Yang Ming Chiao Tung University , Taipei , Taiwan
• 3 Institute of Community Health Care, College of Nursing , National Yang Ming Chiao Tung University , Taipei , Taiwan
• 4 Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation , King's College London , London , UK
• 5 Department of Nursing , National Taiwan University Hospital , Taipei , Taiwan
• Correspondence to Dr Ya-Ping Lin, Department of Medical Humanities and Education, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; arete{at}nycu.edu.tw

Respect for patient autonomy is paramount in resolving ethical tensions in end-of-life care. The concept of relational autonomy has contributed to this debate; however, scholars often use this concept in a fragmented manner. This leads to partial answers on ascertaining patients’ true wishes, meaningfully engaging patients’ significant others, balancing interests among patients and significant others, and determining clinicians’ obligations to change patients’ unconventional convictions to enhance patient autonomy. A satisfactory solution based on relational autonomy must incorporate patients’ competence (apart from decisional capacity), authenticity (their true desires or beliefs) and the involvement level of their significant others. To that end, we argue that John Christman’s procedural approach to relational autonomy provides critical insights, such as the diachronic or socio-historical personhood, sustained critical reflection and his recent explication of the nature of asymmetrical relationships and helpful interlocutors. This study reviews Christman’s account, proposes minor modifications and advocates for an integrated three-dimensional model for medical decision-making. Clarifying the relationship among the three elements promotes an ethical framework with a coherent understanding of relational autonomy. This model not only provides a descriptive and normative framework for end-of-life care practice but also reconsiders the nature of the clinician–patient relationship and its normative implications. We further present a case study to illustrate the merits of our proposed model. Altogether, our proposal will help navigate complex medical decision-making, foster trust and negotiate shared values between patients and their significant others, particularly in end-of-life care.

• Relational Autonomy
• Decision Making
• Terminal Care
• Professional-Patient Relations

Data availability statement

No data are available.

https://doi.org/10.1136/jme-2023-109818

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Introduction

In end-of-life care, intricate decisions on whether to undergo invasive interventions or withhold or withdraw life-sustaining treatment involve not only great uncertainty but also tension between the patient’s self-determination and the interest of third parties. Respect for autonomy is widely asserted as a key arbiter, operationalised through assessing patients’ decision-making capacities and fulfilling their treatment preferences. 1 However, this principle’s role as an ideal ethical panacea is increasingly being challenged, particularly from the perspective of relational autonomy (RA).

Originally proposed in political and social philosophy, RA criticises the mainstream individualistic interpretation of autonomy for its omission of social connectedness as the quintessence of human existence and external forces on one’s autonomy. 2–4 RA has been increasingly adopted to resolve end-of-life issues, 5–9 and its proponents recognise that the clinician–patient relationship has important ramifications in fostering patient autonomy. 10 Three ethical recommendations are commonly highlighted for clinicians: (1) merely securing patients’ informed consent is insufficient to respect their autonomy; (2) consulting or involving patients’ significant others in the decision-making process is desirable and; (3) one must sensitively deal with relevant historical, religious, cultural and social contexts that influence patient autonomy.

Despite these laudable recommendations, clinicians struggle with knotty dilemmas: how to ascertain the true beliefs of their patients, how to meaningfully engage with various parties, 11 and the potential disagreements among them. 12 13 Further, given a patient who firmly endorses a rather unconventional cultural stance or personal conviction, should a dissenting clinician attempt to proactively change the patient’s perspective? 14

Scholars generally endorse competence and authenticity as two essential conditions of autonomy, subject to specification by each theory. 15 As a specific theory of autonomy, RA purports that individuals must possess some necessary competence apart from ordinary decision-making capacities and act according to their true desires or authentic selves. 3 Some scholars propose an interdependent decision-making model that justifies different modes of involving others , depending on the patient’s capacity or competence. 11 However, this model fails to incorporate the patient’s authenticity and thus does not completely align with RA. Contrary to some early critics, 16 17 authenticity has gained considerable traction in bioethical discourse. 18–21 Incorporating the authenticity condition of autonomy may produce a thorough, coherent RA solution to the above-mentioned dilemmas. To the best of our knowledge, only one study 8 has attempted to balance all three essential elements (ie, patients’ competence, authenticity, and the involvement level of others) by using Mackenzie’s multidimensional theory of RA, 22 however, without contemplating any potential alterations to the nature of the clinician–patient relationship.

In this study, we refer to a largely undervalued resource as a better theoretical construct: John Christman’s theory of RA. Christman’s theory of RA has recently received considerable attention from bioethicists in terms of ethical issues involving deep brain stimulation, 23 psychiatric disorders, 24 cognitive enhancement, 25 genetic counselling, 26 biobanking, 27 advanced directives for dementia patients, 28 29 shared decision-making (SDM) 30 and organ donation. 31 Nevertheless, these studies often use Christman’s theory in fractions, primarily based on his famous explication of the authenticity condition of autonomy. This may be because of the publication lag between Christman’s contributions and his sequential minor revisions, making it difficult for bioethicists to track his account. Nevertheless, his recent view of the nature of asymmetrical relationships holds great potential for reconciling ethical conflicts in end-of-life care, lending a critical lens to reflect on clinicians’ roles in actual clinical encounters.

We believe Christman’s theory could contribute to two veins. First, with two minor modifications to his theory, we propose a three-dimensional decision-making model that fully agrees with RA. This integrated model provides a descriptive and normative basis for end-of-life care. Second, this theory could explain the nature of the clinician–patient relationship by emphasising that clinicians should respect and foster patient autonomy. In this context, this study uses an illustrative case to demonstrate how clinicians can facilitate meaningful interactions with various parties to enhance patient autonomy during clinical encounters.

Revisiting John Christman’s account

Some understanding regarding the categorisation of RA is necessary here. There are two types of relational autonomists: proceduralists and substantivists. Proceduralists commit to ‘content-neutrality’ and do not provide a normative standard to determine the ‘rightness’ of the agent’s choice, while substantivists place certain normative constraints on the contents of agents’ preferences. 3 In this study, we commit to justifying an ethical solution in a procedural sense by pacing Christman’s stance. This section first lays out Christman’s original position and then proposes modifications that lead to a distinctive ethical approach to end-of-life care decision-making.

Christman’s diachronic or socio-historical conception of self maintains that everyone has a unique trajectory of growth, consciously or not, explicitly or implicitly accepting or rejecting numerous social norms across their lifespan. Although individuals might encounter countless ambivalences about their true beliefs or possible tensions between beliefs, or they could never elucidate the formation of certain beliefs, Christman encourages us to embrace such a human reality: an individual who can always clearly identify their beliefs with wholehearted endorsement is virtually non-existent. 32–34 Hence, this theory rejects the Frankfurtian and Dworkinian hierarchical model of desire (ie, identification and endorsement). Moreover, it contrasts with the time-slice or ahistorical conception of self, which devoids individuals from their intimate experiences, viewing their living history as irrelevant to selfhood. 34–36

Perceiving selfhood in a diachronic way thus affirms that one’s authentic beliefs cannot settle on the functioning of faculties at a given time but hinges on subjective approval of personal history. The same traits can be reflected over time and under different circumstances to produce a coherent autobiography or an appropriate narrative. Christman calls this reflective process ‘ sustained critical reflection ’ (SCR), which ensures that certain traits can endure through an ever-growing personal history, better reflecting one’s true self 34 (p152) . Christman is not proposing ‘any actual reflection take place on the characteristic in question; nor does it demand that wholesale self-evaluation from a disembodied standpoint take place,’ instead, he claims that occasional, tokenistic ‘ hypothetical and piecemeal ’ reflection ‘in light of the history of the factor’s development to take place, [one] would not feel deeply alienated from the characteristic in question’ 34 (p145, emphasis added in italics) .

Accompanied by the SCR, Christman used a non-alienation test to determine whether certain traits were counted as authentic. Being alienated involves not only one’s cognitive judgement but also one’s salient emotional arousal, strong disapproval and intense resistance towards certain traits. Christman viewed subjective non-alienation as a good basis for instantiating one’s ‘ diachronic practical identity’ 34 (p151) . Borrowing Christine Korsgaard’s theory of practical identity, Christman asserts that a well-consolidated, non-alienated practical identity not only provides motivation for agents to act authentically but also elicits their ‘ reflexive self-affirmation ’ upon their identity, promoting their self-regarding attitudes (ie, self-trust and self-confidence) 37 (p222) . Acknowledging that individuals are hardly detached from their social roles, Christman expands SCR to include publicly available categories, allowing one to examine whether a description of certain social roles (ie, mother, teacher) could reflexively pass the non-alienation test, apart from solely focusing on the private category of personal desire or motivation 37 (p219-220) .

To reckon as a competent agent, Christman maintains that one only needs minimal social, bodily, affective and cognitive competence to engage in SCR; the lack of self-regarding attitudes is not necessarily a prior precluding factor 34 (p182) . However, the reflective process might also need to be free from constraining factors, such as ‘in an uncontrollable rage, or while on heavy doses of hallucinogenic drugs, or having been denied minimal education and exposure to alternatives’ 34 (p147) . Since this depiction does not impose sophisticated or complex requirements, it is firmly in accord with Christman’s commitment to broadest inclusivity in political and social circles; it reaffirms his long-standing stance as a proponent of anti-perfectionism by rejecting to preclude people’s political and social participation only based on specific moral standards external to their convictions. 38

More recently, Christman has acknowledged that third parties or interlocutors could aid in forming practical identities by proposing a joint deliberation model that presses a more relational approach to RA. 37 39 40 Christman has revised his theory to consider ‘asymmetrical relationships,’ reconciling potential paternalist charges on RA. While paternalism might be difficult to eliminate in this context, the advantaged actor might decide whether the best advice or intervention is to restore the vulnerable person’s sense of autonomy depending on the latter’s evolving practical identity 39 (p379) . In some cases, Christman suggests the advantaged, such as social workers, not only ought to assess the vulnerable’s autonomy—a requirement to respect their autonomy—but also bear an obligation to value their autonomy and facilitate their sense of autonomy 39 (p373, p379) . Further, Christman also underlines that the advantaged must avoid performing anti-social attitudes towards the vulnerable, which could posit a detrimental effect on the latter’s autonomy 39 (p381) . To maintain the proceduralist ‘content-neutrality’ commitment, Christman suggests that, while the vulnerable might feel alienated from their previous autobiographies or entirely change their perspective after accepting advice or intervention, they need to provide at least a ‘ process-independent reason ,’ indicating that the change of mind has nothing to do with the intervention itself, to avoid potential undue influence from the powerful actor. 40

An integrated decision-making model of RA

Terminally ill patients often encounter deep uncanniness; they experience profound life-transformative events, such as unfamiliarity with their currently ill bodies, first-time experience living in wards, inexperienced communication with medical teams and duelling with family members’ loaded emotions. This uncanniness not only frustrates them but ultimately undermines their RA. Focusing solely on one’s decisional capacity or treatment preferences at the decision-making point cannot effectively discharge the ethical duty of respecting patient autonomy.

To that end, operationalising Christman’s RA theory, this section integrates an individual’s competence, authenticity and involvement level of significant others into a unified, three-dimensional framework. Our proposal raises the need to reinvigorate the need to maintain good clinician–patient communication and is not intended to promote a direct, hands-on to resolving ethical dilemmas. As noted by Entwisle et al , ‘[r]elational account will not generate simple action lists for clinicians that guarantee protection for patients’ autonomy’ 10 (p744) ; clinicians must attend to the context-specific nature of each encounter and patients’ characteristics. We elaborate on the relationships among the key elements and discuss a minor modification to Christman’s original account: relaxing the competence condition to allow a broader spectrum of patients to engage in SCR.

Competence and authenticity

A comprehensive theory of RA must define a clear relationship between competence and authenticity. According to Christman’s theory of RA, stake detachment between a patient’s current episodes and past historical narratives undoubtedly interrupts socio-historical selfhood. To better capture the traits that truly reflect a patient’s autobiography after experiencing drastic events, clinicians can first invite the patient to engage in SCR and use the non-alienation test. An appropriately constructed autobiography could, in turn, serve as an essential reference for medical decision-making and determining the treatments that align with a patient’s authentic wishes. In addition, clinicians can help patients rethink their expectations of their multiple social roles, enhancing reflexive self-affirmation.

Regarding the competence condition, patients’ fluctuating conditions and possible acute situations may seem too demanding to engage in SCR. As stated above, Christman maintains that only minimal social, bodily, affective and cognitive competence are required to engage in SCR. Patients with mental capacity or consciousness impairment (eg, dementia, brain injury, frailty or delirium due to deteriorating illness), temporary emotional distress (eg, anxiety or depression), psychiatric disorders (eg, schizophrenia or bipolar disorder) and learning disabilities (eg, people who are illiterate or have little or no speech) might have increased disadvantaged of being precluded the chance to express their preferences or wishes. 41

Christman’s competence requirement reminds clinicians to resist the temptation to forgo engagement with patients unwarrantedly based solely on their disease category. A person with one of the health conditions stated above does not necessarily lack the capacity to make a specific decision and engage in SCR, unless evidence proves that this is not possible by any means. 42 One may lack the capacity to make some decisions (eg, to decide on complex financial issues) but can still make other decisions (eg, to decide what items to buy at the local shop). Hence, not only clinicians ought to engage with their patients substantially and creatively, but future research must also be encouraged to develop feasible communicative tools and techniques for clinicians to meaningfully engage with patients with special needs. Granted, when individuals are concerned, patients in a persistent vegetative state, irreversible coma and certain severe psychiatric and learning disability conditions might be deemed unsuitable to engage in SCR. Clinicians and significant others may determine these patients’ authentic wishes, which will be addressed in the following discussion.

However, we contend that a subpart of Christman’s competence requirement—one must be free from the constraining factors—must be relaxed to maintain his ambit and include a broader range of individuals in healthcare settings. Particularly, Christman’s original position precludes people ‘having been denied minimal education and exposure to alternatives’ from engaging in SCR. This condition must be dropped in the end-of-life realm, as it might deny their opportunity for critical reflection and result in the unilateral exclusion of certain groups or people, impeding Christman’s anti-perfectionist stance. By recognising that some patients might be too deprived to form their authentic wishes, clinicians and the interdisciplinary treatment team must always allocate sufficient time to continuously engage with and consult patients to understand their perspectives to the greatest extent. Moreover, clinicians could invite significant others’ input to construct possible contours of patients’ autobiographies. However, if clinicians’ prudence deems patients susceptible to familial malfunctioning or interpersonal dominance, they should consider limiting the perpetrators from speaking on patients’ behalf. Given the best efforts to draw possible historical profiles of patients, and they are comfortable with, or at least not opposed to this narrative, we contend that it is sufficient to locate patients’ non-alienation. We believe this does not oppose Christman’s SCR requirement that the patient has engaged in ‘hypothetical and piecemeal’ reflection, and overdoing patients might not be beneficial to building trust towards clinicians. Additionally, appealing to substituted judgement standards straight away might further strip patients of autonomy.

In figure 1 , the two extremes of the continuum reflect the probability of performing autonomous decision-making: ‘likely autonomous decision’ and ‘unlikely autonomous decision’. The former implies that an individual can engage in SCR and is not alienated from their basic organising values and commitment in light of historical processes. The latter implies that an individual cannot engage in SCR and that their decision cannot be explained by their socio-historical understanding. Between these extremes, a plausible autonomous decision could coincide with changes in an individual’s critical reflection ability, and it must be assessed whether this decision aligns with or deviates from the individual’s fundamental life-long values and goals.

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Competence and authenticity. *C= basic organizing values & commitments of an individual.

Competence and involvement level of significant others

Largent et al have elaborated on the relationship between an individual’s capacity and the involvement level of significant others in medical decision-making. 11 Their interdependence model proposes a continuum between ‘total independence,’ where patients with full capacity can decide for themselves, and ‘total dependence’, where patients without capacity would need a surrogate to speak on their behalf. Between these extremes, the individual’s capacity level and various combinations of significant others involved in the decision-making process exemplify the interdependent nature of the decision-making continuum (eg, in the form of supported decision-making and permission plus partial involvement).

We adapted Largent et al ’s model and applied Christman’s conceptual understanding of ‘competence’ to propose a revised model as seen in figure 2 . Building on the proposed changes in Christman’s condition of competence, this model values one’s ability to perform SCR as well as the involvement of others during the decision-making process. Patients without a bare minimum of competence cannot decide for themselves (lower-left corner of figure 2 ) and should be considered rare in real clinical settings. Moreover, even if patients possess full competence, they could voluntarily delegate their decision-making authority to others (lower-right corner of figure 2 ).

Competence and involvement level of significant others.

Apart from patients’ significant others and surrogates, healthcare providers can use their expertise to partially alleviate barriers for patients to enable them to exercise competence, such as by restoring appropriate cognitive or physical functions and reducing physical and/or psychotic distress. As illuminated by Christman, clinicians ordinarily in a superior position could use communicative skills to improve patients’ self-regarding attitudes and avoid anti-social attitudes towards them. Certain communicative and social conceptions, such as cultural competency, 43 structural competency, 44 and epistemic justice, 45 must be imbued into clinical conversations. Tackling clinicians’ unconscious, implicit biases towards certain patient traits 46 47 and raising awareness about disempowering daily language could better equip clinicians to empower their patients. 48 Without such prior readiness, clinicians might not detect anything extraordinary in their patients and be unable to resolve ethical dilemmas sensitively by considering each patient’s uniqueness.

Moreover, when medicine cannot restore a patient’s competence (eg, permanently incapacitated), clinicians could determine which decision-making standards should be applied in collaboration with patients’ significant others or surrogates. We agree with Scheunemann et al that if the surrogates hold sufficient information to make decisions that accord with the patients’ authenticity, this standard should prevail over the best interest standard. 19 Hence, clinicians need to robustly and sensitively engage with surrogates, especially those experiencing psychological distress and grief.

Authenticity and involvement level of significant others

According to Christman’s theory of RA, once individuals’ decisions are not alienated from their life values and commitment after exploring their historical experience and self-identity, certain competence conditions are satisfied. We further echo Christman’s characterisation of helpful interlocutors, showing that clinicians, and not physicians alone, play an equally paramount role as significant others in coconstructing a patient’s autobiography. 11 19

In our approach, desirableness includes patients’ significant others in decision-making; however, we elucidate what clinicians might contribute. Some proponents of SDM have highlighted its nature as an ‘existential journey,’ viewing patients from a whole-person perspective rather than mere patients. 49 50 As Gulbrandsen et al highlighted, patients’ dependency on medicine and health professionals could invariably be seen as putting trust in this asymmetrical relationship. Taking a relational view of patients’ selfhood, while good cure strives to accommodate patients’ physical or bodily related vulnerabilities, good patient-centred care would need to take their delicate relationalities and social needs onboard, particularly their inevitably interrupted sense of selfhood. As a ‘curator’, the clinician needs to tailor appropriate strategies for conducting SDM for each patient, adjusting the content of the daily clinician–patient conversation, and working jointly with the patient to rebuild their new sense of selfhood and existential meaning for consecutive life 49( p1508) .

Moreover, numerous practical techniques, such as the ‘life review’ approach and lifeline interview, have also been developed to guide clinicians in working with patients and constructing treatment preferences based on their socio-historical backgrounds. 51 52 These trends have coincided with Christman’s ethos. As mentioned above, clinicians must be equipped with certain communicative skills and mindsets to better engage with patients and their significant others. Recently, a group of clinician scholars have shown the feasibility of the ‘lifeline interview’ method for advanced lung cancer patients. 52 In this study, these Japanese patients are asked to draw a consecutive line on a formatted graphic to describe the magnitude of the ups and downs of certain life events. This process is accompanied by a semistructured interview guide conducted by the research team to better elicit the reason why patients put a certain magnitude towards each life event and record whom the patient would want to engage in the SDM or advanced care planning process. The authors claim their work is feasible mainly to help patients ‘to rediscover their values and strengths’ even in a country that usually sees talk of death as taboo 52( pE142) .

Clarification and implications

We have proposed a three-axis model of RA in end-of-life decision-making, enabling more contextual medical decision-making practices. Therefore, we have shown that integrating the three elements (competence, authenticity, and involvement level of significant others) for end-of-life care decision-making is theoretically possible within the ambit of RA and largely explains the core insight of current end-of-life care practices.

We do not prescribe any concrete marker(s) to indicate potential signals of the patient’s alienation or what milestone(s) should be achieved in the clinical encounters. Although we encourage the development of practical tools and educational curricula, we urge clinicians to exert their practical wisdom to unearth delicate details in each conversation session and act responsively. Busy clinicians might be relying on the prescribed marker(s), thus creating a perverse incentive for them to disregard potential signals from their patients and undermining their ethical sensitivity in the long run.

This study’s model has two implications. First, it might appear that the SCR and non-alienation test are not different from other mechanical procedures, such as decision-making capacity assessment. By contrast, while the latter might be executed without robust bidirectional engagement between clinicians and patients, the former urges clinicians to exemplify their professional competence by diligently working with various parties to co-construct an autobiography that best fits the patient’s authenticity. Hence, a proceduralist does not necessarily adopt a non-interfering formalistic stance but is open to meaningful humane interaction and healthcare within the ambit of the RA. Second, this model urges clinicians to play an active role in constructing patients’ autobiographies, underlining an interdisciplinary approach to end-of-life care. Although physicians and nurses bear the primary responsibility for the care plan, the involvement of pain management, bereavement, holistic care and spiritual care share differential weights depending on the situation.

The clinician–patient relationship and relevant obligations

To better characterise the obligations borne by clinicians and patients, we must rethink the asymmetrical clinician–patient relationship. We agree with Entwisle et al that clinicians have a general duty to support patient autonomy but maintain that it is supererogatory to restore patients’ self-regarding attitudes in every instance. 10 Although one needs to possess some social skills to develop and exercise autonomy, it is distinct to state that clinicians must instil or foster these skills in patients. A proceduralist only needs to adopt an ‘interpretive model’ of the clinician–patient relationship to ‘reconstruct the patient’s goal and aspirations, commitments and character’ 53( p2222) .

Building on the classic procedural-substantive RA debate, the substantivist might worry that patients’ elicited beliefs might be influenced by ‘adaptive preferences’, hence undermining their capabilities for developing and exercising RA. 3 When Mackenzie presents a female patient whose practical identity ‘is governed by the norms of traditional femininity’, she decries the procedural account of RA even operationalises with the non-alienation test. The patient might be so oppressed that she could not feel alienated from her belief 14( p518, 521) . She further charges clinicians an obligation to proactively shift patients’ adaptive preferences to enable them to discover alternatives 14( p528) .

Against this backdrop, we err on Christman’s assertion that even if one is genuinely influenced by adaptive preference, it does not automatically preclude them from exercising RA on a particular decision, including medical decision-making. 34 37 It seems inappropriate to value patients’ global autonomy 1 , and this overarching goal may overextend the mission of medicine, especially in the end-of-life realm. Recently, prominent subtantivists also admit that ‘[h]ealthcare professionals cannot be expected to secure the global autonomy of healthcare recipients’ 4( p80) . As shown above, clinicians should work jointly with their patients and significant others to produce a coherent autobiography. Patients’ dependence on clinicians is best explained as they put an equivocal trust in their power, clinicians not only to relieve their physical illness but also seeking to build a new sense of selfhood for them. 49 If we are correct that the procedural approach of RA is best to adopt an interpretive model of the clinician–patient relationship, attempting to proactively change patients’ unconventional convictions would obscure the opportunity to uncover their true beliefs and hence violate their autonomy, not to mention that patient would lose trust to their clinicians momentarily if clinicians persistently challenge their basic life commitments.

Additionally, even leaving aside whether there is a universal understanding of ‘adaptive preference’, it is unwise to label all unconventional beliefs under this category. As Quill Kukla (writing as Rebecca Kukla) shows, given that clinicians use their authority positively to enable patients to ‘critical engagement with their own healthcare practices’, it is justified to ascribe patients who fully delegate their decisional authority to clinicians as autonomous 54( p40) . Some might argue that such patients could be motivated to lower their cognitive dissonance during decision-making or to please their clinicians. However, this objection does not present a unique problem given that the conclusion is reached through robust conversations with clinicians and that their competence and authenticity do reflect that.

Under this clinician–patient relationship model, we largely agree with Lewis, contending that these parties are engaging in a bidirectional, mutual-recognition relationship and each must be answerable to the other, enabling the co-production of medical decision-making 30( p125-126) . For clinicians, proceduralists confirm numerous established obligations (eg, privacy and confidentiality) and impose additional obligations. Although clinicians are permissible to incorporate third parties’ opinions or convictions in decision-making, they cannot coerce or manipulate patients’ decision-making by arbitrarily limiting the scope of information flow and treatment options. Furthermore, clinicians are obliged to assess whether patients’ wills and choices contradict medical norms, even when patients exercise proper competence and authenticity.

Patients, in turn, are obligated to provide ‘appropriate reasons’ for their choices, inform those who will be influenced by the decision (ie, clinicians, family members, and significant others), and consider the latter’s views in their deliberations 30( p130) . Then, combining Christman’s theory, must patients provide ‘process-independent reason’ when changing their minds? Notwithstanding this legitimate coercive concern, we believe this should not be the case. In contrast to Christman’s example as a social worker, the end-of-life dialogue might be the only channel for patients to engage in reflection, perhaps the only one in their lifetime. As medicine might not be intended to promote patients’ global autonomy, requiring patients to provide a process-independent reason could overburden patients facing life-threatening conditions. It may necessitate disclosing excessive personal information to justify a changing stance, disproportionately bleaching their privacy. Additionally, the worry of ‘adaptive preference’ must not divert attention to hold the medical enterprise to a higher bar and take serious care of each patient by constructing their unique autobiographies.

A reiterative reflective framework is essential for procedural accounts of RA that are not prescribed positively. This framework can become integral to clinical practice, particularly in the context of end-of-life care. In the remainder of this paper, we use an illustrative case study to demonstrate how our three-dimensional RA model contributes to real-life end-of-life care decision-making.

A case study

Consider the following scenario: 2

Shu-Fen is a 63-year-old woman who has terminal bone cancer. She is being cared for by her daughter, a single mother with two young children. Shu-Fen has decided to refuse all life-sustaining treatments to reduce physical suffering and avoid becoming a burden on her daughter and society. The healthcare team concludes that she possesses full decision-making capacity.

Recently, Shu-Fen underwent a below-the-knee amputation and is having to come to terms with the prospect of permanent disability. Her illness left her feeling guilty towards her daughter and questioning her own self-worth. Shu-Fen expressed her wish to the healthcare team to cease any further treatment and let nature take its course if the cancer spreads to other parts of her body.

However, at times, when Shu-Fen experiences pain from cancer, she longs for the healthcare team to save her or at least allow her to spend more time with her daughter and grandchildren after talking and being with them.

Seeking to understand the daughter’s perspective, the healthcare team discusses with her. They observe that Shu-Fen is a self-abnegating woman who always puts family needs before her own and is used to sacrificing herself for others. Her daughter explains that her mother has experienced hardship since childhood and is not used to being dependent on others. However, she has willingly taken on the responsibility of caring for her mother and pleads with the healthcare team to do everything possible to save her.

Recognising the importance of understanding Shu-Fen’s desires and ensuring that she makes informed decisions, the healthcare team approaches her to explore her thoughts. However, she declines to express her views directly, indicating her preference to leave the decision-making authority to her daughter. Privately, though, she frequently hints that she believes her life has been fulfilling enough and does not want to burden others further.

The healthcare team finds itself in a difficult situation, as it has been unable to make substantial progress in direct communication with Shu-Fen. They are left with no choice but to discuss with her daughter, which raises concerns about whether this approach fully respects and honours Shu-Fen’s autonomy and wishes.

Shu-Fen’s case exemplifies a common scenario in clinical settings, especially in Asian contexts. This case demonstrates various complexities: (1) Shu-Fen has expressed seemingly conflicting feelings, expectations and preferences regarding her illness and death; (2) Shu-Fen and her daughter disagree; (3) Shu-Fen delegates decision-making authority to her daughter but occasionally expresses her preferences, making it challenging for others to follow. Some patients may be hesitant or reluctant to make decisions for themselves, lack a sense of autonomy, or be unfamiliar with their rights in healthcare decisions. They may not even consider themselves to have the authority to make decisions. In such cases, healthcare teams often communicate with patients’ family members and act on their decisions. While this approach may be well intentioned and ease the decision-making process, it can result in disregarding the patient’s agency and autonomy in healthcare.

First, patients often have oscillating preferences rather than clear-cut or consistent. As noted by Ohnsorge et al , the coexistence of opposing wishes can be authentic, multilayered experiences and moral understandings at the end of life. 55 Recognising that patients’ seemingly contradictory thoughts and requests can be part of the process of meaning-making and negotiating normative claims on a personal level and through interactions with others, healthcare professionals can adopt a more nuanced approach 55( p630) . Through the lens of a diachronic socio-historical account of selfhood, the patient’s self is an ongoing, transforming process. By engaging in open and empathetic discussions with Shu-Fen, the healthcare team can evaluate the extent of her competence in reflecting on her fundamental values, desires, and beliefs, as well as her expectations of her social roles as a mother and grandmother. It is vital to facilitate a decision that is not alienated from her diachronic practical identity. In the terminal phase, patients approach death with each passing moment. Self-understanding may be more important than consistent decision-making. Exploring the patient’s authentic self and collaboratively composing an autobiography and narrative that embraces evolving perspectives may be the proper way to honour RA in end-of-life care.

Furthermore, the development of RA transcends mere individual contemplation–a procedure of internal critical reflection–and transforms into an intersubjective, interactional accomplishment that unfolds within the fabric of communicative practices. In particular, one’s narrative may become more explicit through joint reflection and support from others. As argued in the previous section, healthcare teams, instead of being detached from the whole process, are obligated to provide support, such as offering medical information, alleviating symptoms, and enhancing patient confidence and self-esteem, to reduce the barriers to patients’ reflection and decision-making and to take an active part in the co-construction of patients’ autobiographies. In this case, we propose that clinicians should not limit their role to merely assessing Shu-Fen’s decisional capacity and freedom of choice; instead, they should try to engage both Shu-Fen and her daughter in a meaningful dialogue to exercise Shu-Fen’s RA. When clinicians actively support patients in exploring and reflecting on their authentic wishes, it builds trust and strengthens the healing relationship. 56

Our proposed model also considers the broader socio-cultural and healthcare contexts and the interpersonal and social dynamics within which one is situated. Therefore, when supporting the decision-making process of terminally ill patients, it is essential to be mindful of how their past experiences and social and structural backgrounds interact and how these relationships can shape their identities and, in turn, either enhance or hinder their autonomy. In Shu-Fen’s case, her upbringing and social norms shape her perspective. As a woman and mother, she may have become habituated to self-sacrifice, prioritising the well-being of her family over her own. Nevertheless, pulled in different directions by her intersecting relationships with her daughter and the clinicians, she remains uncertain about her true preferences.

Closer examination revealed that Shu-Fen’s perspective evolved as she interacted with her family. Initially, Shu-Fen perceived herself as a burden and thought that the best way to benefit her daughter was to die earlier. In this case, the healthcare team should regard Shu-Fen’s refusal of treatment as an opportunity to create an open space for meaningful dialogue. This would allow the patient to express her reasons for refusal and negotiate treatment choices that may deviate from standard medical advice. Additionally, it provides an occasion to communicate with her daughter and clarify her understanding, considering what these relations mean to her identity and, hence, her decisions. Through these open and supportive dialogues and interactions, the family members can foster mutual understanding and realise that the daughter also depends on Shu-Fen, values her company and desires her to live longer, revealing the interdependence of their relationship. These relationships facilitated Shu-Fen in developing a stronger sense of self-worth and self-trust, improved her articulation skills, fostered self-reflection over time and enabled better integration of her practical identity and social values during the decision-making process.

How should we approach the role of Shu-Fen’s daughter? Engaging significant family members in communication and decision-making is crucial when patients prefer family-led care. This involvement should neither be perceived as hindering or impeding the patient’s autonomy nor should it suggest substituting for the patient’s decision. By integrating these three interrelated dimensions into the decision-making process for end-of-life care, the healthcare team seeks to foster Shu-Fen’s competence and authenticity in a ‘cooperative deliberation’ process with others. 40 Respecting Shu-Fen’s RA in a procedural sense does not compromise her choices in clinical practice. It is important to note that we should avoid endorsing East/West cultural stereotypes and perpetuating the false dichotomy between Eastern and Western principles of autonomy. 57 58

This study enriched the application of RA in end-of-life care medical decision-making. Our primary contribution lies in modifying John Christman’s theory, illuminating the nuanced interplay between competence, authenticity, and relational dynamics. We proposed relaxing Christman’s competence condition of autonomy to include the broadest range of patients engaged in SCR. Additionally, we suggested that terminal patients should not be obligated to provide ‘process-independent reason’ when changing their treatment preferences.

Adopting a procedural approach to RA is justified in end-of-life care where strong substantive conditions are inappropriate for terminal patients who should not be compelled to undergo significant changes in beliefs and values unless overt manipulation or oppression is evident. The case of Shu-Fen exemplifies how factors such as illness and oppressive socialisation can affect decision-making, prompting a shift in focus from liberating patients from external influences to promoting their competence and authenticity in autonomous decision-making.

Moreover, our integrated three-dimensional decision-making model for RA refines Christman’s socio-historical account and offers descriptive and normative insights into end-of-life care. This model emphasises the dynamic and evolving nature of the authentic self and recognises the fundamental roots of autonomy in intersubjective and dialogical processes, thus providing a more contextual framework for medical decision-making. In the ongoing pursuit of advancing RA in end-of-life care, future studies should build on our model and provide concrete suggestions for enhancing clinicians’ competencies through professional development.

Importantly, advocating for a procedural approach to RA does not imply an endorsement of a ‘thin’ or ‘minimalist’ conception of autonomy. In the terminal phase, patients undergoing a stressful ordeal due to life-threatening illnesses make decisions concerning and depending on clinicians and other professionals. Our theory of RA contributes a meaningful explication to the nature of the clinician–patient relationship, emphasising the ethical responsibility of healthcare teams in responding to patients’ needs and expectations and fostering their autonomy. It provides a practical framework for navigating complex decision-making scenarios, fostering trust and negotiating shared values between patients and their families. By embracing a relational perspective and considering the dynamic nature of authenticity, we hope to pave the way for healthcare professionals to engage in meaningful and supportive interactions with patients. This approach ensures that autonomy is respected and actively fostered throughout the challenging journey of end-of-life care.

Ethics statements

Patient consent for publication.

Not applicable.

Acknowledgments

We thank Wenmay Rei, KLC, HWC, YYL for their thoughtful comments on the initial version of the manuscript. We are also grateful to two anonymous reviewers for their careful reading and insightful comments.

• Beauchamp TL ,
• Childress JF
• Mackenzie C ,
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• Mackenzie C
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K-FF and Y-PL are joint first authors.

Twitter @YaPingLIN84

Contributors KFF and YPL contributed equally to this work. All listed authors contributed to the conceptualisation of the manuscript. CPL and YCC critically reviewed and revised the manuscript. All listed authors approve the final manuscript and accept accountability for all aspects of the work. No AI technology has been used throughout the drafting and revision of the manuscript. YPL is the guarantor of the study.

Funding This study was funded by Ministry of Science and Technology, Taiwan (MOST 111-2314-B-A49 -012 -MY3).

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

↵ While ‘local autonomy’ refers to one’s exercise of autonomy on a particular decision, proponents of ‘global autonomy’ go further to claim broader oppressive social structure hinders one’s genuine autonomy. 3

↵ This case is inspired by the clinical experience of the authors CPL and YCC with cancer patient care.

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