Developing a ‘moral compass tool’ based on moral case deliberations: A pragmatic hermeneutic approach to clinical ethics

Abstract Although moral case deliberation (MCD) is evaluated positively as a form of clinical ethics support (CES), it has limitations. To address these limitations our research objective was to develop a thematic CES tool. In order to assess the philosophical characteristics of a CES tool based on MCDs, we drew on hermeneutic ethics and pragmatism. We distinguished four core characteristics of a CES tool: (a) focusing on an actual situation that is experienced as morally challenging by the user; (b) stimulating moral inquiry into the moral concepts, questions and routines in the lived experience of the CES tool user; (c) stimulating moral learning by exploring other perspectives; and (d) incorporating contextual details. We provide an example of a CES tool developed for moral dilemmas over client autonomy. Our article ends with some reflections on the normativity of the CES tool, other application areas and the importance of evaluation studies of CES tools.

CES meetings. 4 Although there are differences, the same key elements are present; a group of participants, a facilitator, a method to structure the conversation, one concretely experienced case and a moral question. 5 MCD is an example of an approach in CES that emphasizes the importance of practicing ethical reflection together with practitioners embedded in daily care practices and routines, instead of a more detached reflection on care practices. Furthermore, within MCD the experience and the moral expertise of care practitioners themselves are central, rather than theoretical knowledge of, for instance, an ethicist. 6  2. MCD allows for only a limited number of people to join the reflection (about 8-12 per session). This allows relatively few professionals to learn and profit from the mutual learning process and insights generated by the joint reflection.
3. MCDs are relatively expensive and time consuming (sessions take on average 1 to 2 hr), have to be planned ahead and need a trained facilitator. 8 These characteristics require organizational effort and imply logistical challenges.
4. MCD deals with one individual concrete case. It does not address other, similar cases. If MCD is the only means of CES being used in an institution, there is a risk that the MCD sessions tackle the same kind of moral question over and over again whereas the systemic causes of these moral questions may not be recognized and addressed in a more general way.
In order to deal with these limitations, a large health care organization in the Netherlands where we successfully implemented MCD asked us to develop an additional, tailor-made CES tool based on the insights gained in a series of MCDs that could be used more spontaneously and which could be distributed more easily through the whole organization. Hence, we were challenged to think about how to develop a theme-based tailor-made tool for this organization, inspired by the insights obtained by a series of MCDs on a specific topic. The goal of this CES tool was not to replace MCD but to provide CES complementary to MCD. Given the importance and widespread presence of moral dilemmas concerning client autonomy, the decision was made to focus on this issue. This objective raises important theoretical questions. Which characteristics should the CES tool possess? To what extent can we process lessons learned from earlier MCDs on client autonomy in this CES tool? What kind of results or outcomes should such a CES tool bring about? What kind of normative guidance is possible with the CES tool? In this article we seek to answer these questions.
In the following, we first describe some key theoretical notions of MCD derived from hermeneutics and pragmatism. These theoretical notions concern the concepts moral knowledge and moral learning. Then, we consider the implications of these notions for the development of a theme-based CES tool based on case-based MCDs. We describe the four core characteristics that a CES tool should have, based on this theoretical framework. Then we provide an example of a CES tool developed for moral dilemmas addressing the moral theme of client autonomy for a health care institution that provides long-term care to a diverse range of clients (such as elderly care and mental health care). 9 Our article ends with some reflections on the normativity of the CES tool, other application areas and the importance of evaluation research of CES tools.

| THEORE TI C AL BACKG ROUND OF M CD: E XPERIEN CE AND JOINT LE ARNING
We describe the theoretical background of MCD here in a general way.
This means that we focus on two philosophical traditions, i.e. hermeneutics and pragmatism. Rather than going into detail on the different theories and philosophers that belong to these traditions, we focus on the core concepts, philosophical views and common characteristics of both traditions. We will select some key theoretical concepts that help us interpret and specify the proceedings and normative status of MCD as CES. This in turn allows us to formulate some implications for developing a theme-based CES tool based on these MCDs (paragraph 3).
Furthermore, our use of the concepts ethics and morality needs elucidation. We use the concept morality to refer to our moral routines, consisting of a complex web of norms, values, obligations, etc. and reserve the term ethics for the actual discussion of or reflection on these norms, values and obligations. 10 According to this distinction, as soon as people start discussing, reflecting on or questioning their morality, they are engaged in ethics. So a conversation on an ethical issue by the coffee machine, a joint reflection within an MCD meeting, a discussion in an ethics committee or a commentary in an ethics journal are all examples of doing ethics (some obviously more structured then others). We understand ethics as the activity of discussing, researching, asking questions about, scrutinizing or reflecting on an existing morality, it entails being engaged with morality and asking questions about the right thing to do. This reflection on morality, departing from our experience and focusing on moral learning, is the core ingredient of MCD sessions.

| Hermeneutics
According to philosophical hermeneutics, ethics is not merely a matter of theoretical insight, but starts with practical experience. We can only come to know what is morally right by dealing with ethical problems in practice, starting from experience. 11 How one perceives and interprets the world is dependent on one's personal experience, personal history and the norms and values of the culture and family in which one grew up, but also the one's education and professional norms of the organization. Judgements, opinions and deliberations about what is right cannot be made from a neutral, birds eye point of view, but always start from a 'specific here' with all its contextually bound knowledge and information. 12 This means that an ethical question or ethical dilemma is inherently related to the concrete experiences of people involved (i.e. an ethical question or dilemma does not exist independently).
Our embeddedness in the world, according to hermeneutics, implies a specific view on both moral knowledge and moral learning.
We do not possess moral knowledge in an abstract and general way and then apply this moral knowledge to concrete circumstances.
Instead, the understanding and interpretation of our moral concepts is created within the situated contexts of concrete practices. This understanding is also influenced by the historical and cultural context of the knower. So moral concepts like autonomy and dignity acquire meaning through their use within practices over time. What is right always has to be explored in the practice in which the ethical issue arises. 13 This is essentially what is done in an MCD; the meaning and understanding of the relevant moral concepts is explored, shared and contrasted by a group of practitioners through a dialogue on a concrete experience of an ethical dilemma in a practice, involving an exchange of views which are directly related to personal experience. 14 Moreover, which moral concepts are relevant is also explored and discussed by the participants based on their moral experience and not defined beforehand.
In line with this interpretation of moral knowledge, moral learning also gets a specific interpretation. Moral learning starts from a confrontation between our experience and our surroundings. We continuously reflect on, learn from and alter our judgements on the basis of our encounters with the world and with others. The knower and the known are interrelated, and the background of the knower influences what is learned from a specific situation. The complex background that one has acquired by moving through the world influences what one observes and learns from a new situation. 15 This implies that all observers of one situation may learn something different, depending on their specific background by the confrontation with other perspectives. This entails an embodied, social and dynamic theory of moral learning, for which engaging with and being exposed to other practices and viewpoints is essential. According to hermeneutics, moral learning is neither the act of leaving one's views fully behind, nor of reaching a definite, objective view of the situation. The idea is that one understands one's own position as limited, not as totally wrong. Further exposure to new perspectives may lead to new knowledge, but this process does not result in objective knowledge. There is always another perspective, and human learning is always finite. However, this does not exclude the role of ethical theory and critical thinking in hermeneutics. Ethical theory can be of great importance for moral deliberation in specific contexts.
Following this approach, an MCD session can be regarded as a place where moral learning is actively encouraged. The participants 10 Dewey J. (1922,2002).

| Pragmatism
Like hermeneutics, pragmatism emphasizes the importance of concrete practices for our understanding of moral concepts. 18 Instead of searching for an objective or universal moral truth, pragmatism understands our moral concepts as tools that acquire their specific meaning within dynamic contexts and practices. The concept of tools emphasizes the instrumental nature of our concepts.
Correspondingly, our moral concepts should be evaluated on their use and usefulness in practices (i.e. do they solve the problems they were designed to solve? Do they help making sense of a situation? Do they enable successful responses to new problems?). 19 According to pragmatism, the meaning of moral concepts changes in response to the situations in which they are applied.
According to pragmatism, our morality is embedded in our actions and our self-understanding. This is mostly so self-evident that we are hardly aware of it. The values and norms that one acquires by growing up and learning the norms of, for instance, a profession are most of the time not explicit, but implicitly play a role in the way the professional approaches a situation. We take these implicit values and norms for granted as they are embedded in our (moral) routines, habits, actions, interactions and intuitive moral judgements. The background that is acquired by moving through the world influences what is considered to be the right thing to do; it is one's implicit point of reference. 20 We often live and enact our norms and values instead of reasoning about them in a cognitive way. Our morality shows in our behaviour.
Our moral routines or habits can, however, be challenged in certain situations: for instance when two values are competing in that situation, when one is confronted with another perspective on a situation or when one cannot take one's moral routines for granted any more in the context of a new practice or technology. 21 At such moments, norms and values may become subject of reflection, debate and inquiry. Moral inquiry often starts when a person experiences a problem with a practice, when something needs to be done and one doubts the right course of action. But moral routines can also be challenged by an outsider perspective or an, up until that point, silent voice, like a patient's perspective or the perspective of a minority group. According to the pragmatism of Dewey, moral inquiry is problem oriented instead of theoretically oriented. 22 When we experience a moral dilemma our moral routines are not self-evident any more.
MCD can stimulate a systematic moral inquiry in order to scrutinize our moral routines. 23 In MCD, presuppositions and moral routines are critically reflected upon within the practical situation at hand. In the end, this moral inquiry may lead to new insights about what is morally right, which again may lead to new moral routines.
Take, for example, the implicit view on collegiality of a person. If the person holds the implicit norm that collegiality entails 'always being loyal towards each other', the behaviour of colleagues will be judged by this norm. This may give rise to a dilemma, for instance, when a colleague does something that seems to be wrong, and is disrespectful towards her clients. Should one be loyal towards this colleague and keep silent, or should one take action and try to change the situation? And in case of the latter; what action would be the right one on the situation? Should one confront the colleague or report her to the manager, or intervene when the specific event takes place?
Establishing the specific moral dilemma that this situation entails is personal: for other individuals this example may not even be a moral dilemma. Reflecting upon this situation in an MCD encourages one to make explicit one's implicit norms (of which one may not even

| IMPLI C ATI ON S FOR DE VELOPING A THEME-BA S ED CE S TOOL
Based on the theoretical notions described above, we will now articulate four core characteristics the CES tool should have.

| Characteristic 1: An problem that has been experienced as a starting point
As described above, practitioners start doing ethics when they experience a problem with their moral routines in a concrete situation, i.e. moral inquiry is problem oriented. As a result of a specific experience (that can be anything from a confrontation with the perspective of another person, critical questions from an outside perspective, a new technology or reading a book), one's moral routines do not function as self-evidently as they used to, which is when people often start experiencing moral doubts. At that moment they might experience the need to reflect on their morality. This is the moment in which practitioners might feel in need of CES, which is why the proposed CES tool starts with relating to the concrete issue that is experienced as morally troublesome, rather than with presenting abstract moral knowledge, general ethical issues or a predefined ethical dilemma that is not experienced based.

| Characteristic 2: A focus on moral inquiry into the moral concepts, questions and routines within the lived experience of the CES tool user
Secondly, hermeneutics and pragmatism both emphasize that an ethical dilemma does not emerge from the facts but from a person's experience of the facts. This experience differs according to the person and perspective or the position within the situation (for instance, related to the profession of the practitioner). Where one person may experience great difficulties, the other may not. The CES tool should therefore not define the ethical question beforehand but ask the user to articulate the ethical question for themselves.
Moral concepts acquire their meaning within the concrete care practices and can be different from person to person. For instance, collegiality may predominantly entail 'loyalty' to one person and 'being critical' to another person. According to this theoretical framework, moral concepts cease to have a steady fixed meaning that may be transferred to practitioners (for instance, in a textbook or argumentation card): instead their meaning has to be created by practitioners within their own actions, conversations and practices.
Thus, the CES tool does not start with a definition of, for instance, a concept like autonomy and neither does it search for a definition of autonomy but stimulates reflection on what a concept like autonomy means for the user of the CES tool with regard to their own ethical dilemma and practice.

| Characteristic 3: A focus on moral learning by exploring other perspectives
Moral learning is understood here, in line with hermeneutics and pragmatism, as becoming aware of one's (often implicit) moral routines, prejudices and assumptions, and broadening one's moral perspective in dialogical confrontation with the perspectives of others.
To stimulate reflection on implicit moral assumptions, the CES tool should encourage the user to engage with the perspectives of other stakeholders in the situation at hand. Therefore, the CES tool should challenge the user to look at the situation from different perspectives; for instance, from the point of view of a client/patient, family member or other professional. Rules and regulations, or other normative frameworks can also be interpreted as another perspective. By venturing into what could be of moral importance for these other stakeholders (in terms of values, norms and principles) by trying to put oneself in the shoes of the other, moral learning in terms of becoming aware of one's own perspective and broadening one's moral horizon is encouraged.

| Characteristic 4: Incorporating contextual details
According to both hermeneutics and pragmatism, what is right can only be determined within a concrete situation, incorporating all morally relevant contextual details. This includes the facts, norms and values of the different stakeholders in the situation at hand, but also the relevant rules and regulations that apply to the situation. This means that the CES tool should include contextual details, formulated in the terminology of health care professionals. This requires empirical research, elaborating, for instance, the facilities that are available in a health care organization, the strategies that are often mentioned to handle a moral dilemma etc. This information needs to be reinterpreted by the user and taken into account for the moral consideration of a specific issue.

| C A S E E X AMPLE: DE VELOPING A MOR AL COMPA SS A S A THEMATIC CE S TO O L
To illustrate the four characteristics of a CES tool we describe the actual development of a theme-based CES tool based on a series of MCDs. We refer to the CES tool as a moral compass, because through the learning process the users of this tool themselves develop moral guidance in the specific situation at hand. We use the term moral compass as a tool or instrument that provides CES. With the term moral compass we do not refer to an inner, psychological moral framework, as is done in other literature. 24 The specific context in which we developed the tool was a large health care organization in and around Amsterdam. This organization provides long-term care for elderly people, for people with a mental disability and for psychiatric patients (both ambulatory and in assisted living facilities).
Our research objective was to develop a low threshold CES tool based on a series of MCDs on client autonomy in long-term care, to be complementary to MCD. The aim of the CES tool is to make both the process and the content of a series of MCDs on client autonomy useful, more accessible to a wider group and less time-consuming than a MCD session, thus addressing the limitations of MCD described above. Preliminary research showed that health care professionals in the organization encounter ethical dilemmas related to respecting client autonomy at the one hand and actively intervening for the sake of client's well-being in a situation at the other hand. Whereas the institution aims to provide demand-driven care, professionals experience moral doubts, especially when they feel that the well-being of clients would benefit more from active intervention. Dilemmas included, for instance, whether clients in an assisted living facility should be allowed to eat and drink whatever and whenever they wanted (even when they were at risk, for instance, because of diabetes), whether a client's wish to live independently should be honoured (even when it was doubtful whether they were up to this), and whether clients should be pressed to quit drinking and smoking (even if they had few other joys in life). Because these kinds of issues were omnipresent in the organization we decided to focus the moral compass on dealing with dilemmas related to this particular theme.
We used a qualitative research design in which we analysed both the process and content of a series of MCDs, combined with reflections on the theoretical background of MCD. For the MCDs we used the dilemma method. 25 In total, 28 MCDs (10 transcripts and 18 summary reports) were analysed by means of a thematic content analysis. In various rounds, the results of the analysis were combined with theoretical reflections on CES and moral learning.

The analysis of the 28 MCDs resulted in extra process questions
and concrete content related to client autonomy in the draft of the moral compass (for example, by enumerating possible values and norms that might play a role in dilemmas over client autonomy).
Consequently, the tool was developed and evaluated in three focus groups with health care professionals and adjusted based on their feedback. We have described the actual development of the tool, the empirical analysis of the MCDs and the content and structure of the CES tool in more detail elsewhere. 26 In the following, we describe how the moral compass embodies the four characteristics distinguished above. We describe the CES tool according to the characteristics and chronologically (from question 1 to 6).

| What is your dilemma? An problem that has been experienced as the starting point (characteristic 1)
According to pragmatism, moral inquiry is problem-oriented.
This means that people start reflecting on their morality when they encounter a problem or challenge with their existing moral routines. The moral compass takes an actual moral dilemma that has been experienced as its starting point and stimulates reflection on that experience, instead of offering general moral arguments beforehand. Therefore, the first question that is presented to the user is: 'Q1 Sometimes, it is not self-evident what the right thing to do is. What is your dilemma?' (see Table 1). The

| What causes your moral doubts? A focus on moral inquiry into the moral concepts, questions and routines within the lived experience of the CES tool user (characteristic 2)
The CES tool should and cannot determine beforehand whether or not an ethical dilemma as such exists but asks the user of the tool to formulate her dilemma on the basis of her experience.  Table 1). This question is illus- Each choice has its disadvantages, because you simply cannot do everything that is important. It helps to be conscious of this,

Q6
Are you able to deal with your dilemma after using this compass?
TA B L E 1 Six questions from the moral compass with explanations (translated from Dutch)

| What is important to whom? A focus on moral learning by exploring other perspectives (characteristic 3)
In the moral compass, we use two ways to stimulate moral leaning, in line with the theoretical framework described above. Firstly, the moral compass stimulates looking at the moral dilemma experienced from different perspectives, as emphasized by hermeneutics.
Question 3 reads: 'By placing yourself into the shoes of others, you acquire valuable insight into different perspectives on the problem and on the right thing to do. With each question, ask yourself what would be important to someone, both in the long and short run.
What is important to whom?' The user is asked to place herself in the shoes of the patient/ client and think about the values that could be important for the cli-

| Incorporating contextual details (characteristic 4)
Based on the qualitative analysis of the MCDs, we incorporated The qualitative analysis showed that many moral questions surrounding the theme of autonomy were complicated by the role of the family or by feeling that they were solely responsible for the situation. We also incorporated these aspects in the CES tool because they might be relevant for the user and the dilemma at hand. Finally, the moral compass addresses the question whether the user feels the dilemma has now been sufficiently dealt with. The final question (Q6) reads: 'Are you able to deal with your dilemma after using this compass?' If this is not the case, some follow-up strategies are suggested, such as talking to your team manager or requesting an MCD. These are options that are available in that particular health care organization (in another health care organization, the follow-up options would be different). The recommendation for an MCD also stresses the complementarity of the moral compass and MCD (see Table 1).

| D ISCUSS I ON
We have argued that a CES tool based on MCDs has to have certain characteristics in order to be in line with the theoretical CES approach of MCD. We identified four core characteristics: (a) a moral problem that has been experienced as starting point, (b) a focus on moral inquiry into the moral concepts, questions and rou- may support the user with their own moral dilemma.
One strength of this study is the explicit reflection on the theoretical background of MCD for the development of this CES tool and the theoretical fit between the CES tool and MCD (independent of whether one agrees with this theoretical background). Other scholars have argued that theoretical reflection and consistency is often missing in the development of CES and CES-related tools. 28 Theoretical and normative viewpoints on CES are always implicitly present in CES and its evaluation. 29 In this study, we have been explicit about our theoretical viewpoints and made them part of the development process right from the start. In this way, theoretical reflection can influence the developmental process of the CES tool and steer the qualitative research process. For instance, in the qualitative analysis of the MCDs, we did not look for final answers or consensus, but focused on ingredients for heuristic purposes (e.g. offering examples of perspectives, arguments and values and norms), that were particularly insightful for the participants of the MCD.
In line with the pragmatic and hermeneutic approach we de- to be in accordance with the results and outcomes that we aim to bring about with the CES tool. The tool should, for instance, not be evaluated by investigating whether the use of the compass made a certain decision more easy or certain for the user, but whether moral learning has taken place. Evaluation of this kind of new and innovative CES tool is essential for the further development of CES and for assessing its actual contribution to health care practice.

| CON CLUS ION
In this article we discussed the theoretical framework for developing a theme-based, tailor-made CES tool on the basis of a series of