Rob Reuzel

Interactive technology assessment of paediatric cochlear implantation

Interactive technology assessment is a novel approach to evaluating (health) technology, which philosophically draws from the works of Rawls and Habermas. That is, it seeks to organise a practical setting for discursive ethics in order to find a legitimate basis for policy to be pursued when the technology under scrutiny features a moral controversy. Interactive technology assessment involves a cycle of interviews with all stakeholders, who are explicitly asked to respond (anonymously) to the concerns and issues raised by other participants. This cycle is completed repeatedly, so that a process of vicarious learning develops. This process aims at identifying issues agreed and disagreed upon, on the basis of which widely endorsed policy recommendations can be formulated. This chapter involves an interactive technology assessment of paediatric cochlear implantation. The rationale, the design, and the results are explained, as well as the main ethical aspects of the procedure.ZusammenfassungInteractive technology assessment (interaktive Technologiefolgenabschätzung) ist ein neuer Ansatz zur Bewertung von (Medizin-)Technologie, der in philosophischer Hinsicht auf Arbeiten von Rawls und Habermas zurückgreift, das heißt, sie versucht eine praktische Situation für diskursive Ethik zu organisieren, um eine legitime Grundlage für eine Politik zu finden, die zu verfolgen ist, wenn die betreffende Technologie durch eine moralische Kontroverse gekennzeichnet ist. Zur interaktiven Technologiefolgenabschätzung gehört ein Zyklus von Befragungen aller Interessengruppen, die explizit gebeten werden, sich zu den Bedenken und Fragen anderer Teilnehmer (anonym) zu äußern. Dieser Zyklus wird mehrmals wiederholt, sodass sich ein Prozess mittelbaren Lernens entwickelt. Dieser Prozess hat das Ziel, Punkte zu identifizieren, in denen Übereinstimmung herrscht, und Punkte, über die die Teilnehmer sich nicht einigen können. Auf dieser Basis können dann allgemein gebilligte Politikempfehlungen formuliert werden. Dieses Kapitel befasst sich zum Beispiel mit der interaktiven Bewertung der Technologie der Cochlea-Implantation in Kindern. Es erklärt die Begründung, den Entwurf und die Ergebnisse der Prozedur sowie ihre wichtigsten ethischen Aspekte.RésuméL’évaluation technologique interactive est une nouvelle approche pour évaluer les technologies (médicales), qui tire son origine des travaux de Rawls et Habermas. Cela signifie qu’elle tente de d’organiser une configuration pratique pour l’éthique discursive, afin de trouver une base légitime aux politiques à suivre lorsque la technologie examinée fait l’objet d’une controverse morale. L’évaluation technologique interactive implique un cycle de sondages auprès de tous les groupes concernés, auxquels il est explicitement demandé de s’exprimer (anonymement) sur les préoccupations et les questions soulevées par d’autres participants. Ce cycle est répété à plusieurs reprises, de sorte qu’un processus d’apprentissage indirect se développe. Cette démarche vise à identifier les points suscitant l’accord ou le désaccord, sur la base desquels des recommandations politiques approuvées par une large majorité peuvent être formulées. Ce chapitre porte sur l’évaluation technologique interactive dans le cas des implants cochléaires en pédiatrie. Il présente le raisonnement, la conception et les résultats de la démarche de même que ses principaux aspects éthiques.

Ethics and HTA: Some lessons and challenges for the future

What have we learned? Is there in the contribution to this special theme a clue as to what is the best way of integrating ethical inquiry into health technology assessment (HTA)? Particularly, what is the significance of the social shaping perspective in this respect? In this concluding paper, we attempt to collect the lessons we have learnt and to answer these questions. Of course, our answer will not be the final one. It is difficult to find an appropriate and widely endorsed model of integrating ethical implications in HTA studies, if there is such a single appropriate model at all. But despite reserves, it is equally fair to claim that it is definitely possible to reach beyond what ethical inquiry in HTA too often concerns, namely to conclude that ‘‘the technology raises serious ethical concerns that must be dealt with.’’ This is truly a death sentence, for both HTA and medical ethics, just when their integration is called for. In the remainder of this paper, we address three questions. First, the main question of this issue is: How could ethical inquiry be integrated into HTA? Or in other words: What methods do we have to address moral aspects of technology in a valid and useful way? This question is addressed by discussing the following aspects: How can ethical issues be identified and addressed, and how could the perspective of social shaping of technology add to this? Second: Who is to face the challenge of ethical inquiry? Under this header, we discuss the role of researchers, policy-makers, laypersons, and ethicists. In addition, we address the issue of moral competence. Poiesis Prax (2004) 2: 247–256 DOI 10.1007/s10202-003-0054-1

The role of the evaluator in an interactive evaluation of cochlear implantation.: shaping power, trust and deliberation.

Interactive evaluation involves a deliberative procedure that has been designed to address poorly structured policy problems in the context of power differences between stakeholders. Basically, it consists of an iterative cycle of interviews with these stakeholders. Power differences are dealt with by anonymising the procedure, the researcher acting as a counsellor exchanging claims, concerns and issues between the stakeholders. However, now the researcher himself or herself becomes a powerful figure. This article describes how a researcher, in an interactive evaluation of pediatric Cochlear Implantation (CI), maintained a balance between constructively using his power to help tackle the policy problem and leaving the ownership of the deliberative process with the stakeholders. To some extent, the procedure was designed to this aim. However, success also critically depends on the researchers skills in building trust and prudence in applying rules of argumentation.

Participatory workshops are not enough to prevent policy implementation failures: an example of a policy development process concerning the drug interferon-beta for multiple sclerosis

A possible explanation for policy implementation failure is that the views of the policy’s target groups are insufficiently taken into account during policy development. It has been argued that involving these groups in an interactive process of policy development could improve this. We analysed a project in which several target populations participated in workshops aimed to optimise the utilisation of an expensive novel drug (interferon beta) for patients with Multiple Sclerosis. All participants seemed to agree on the appropriateness of establishing a central registry of Multiple Sclerosis patients and developing guidelines. Nevertheless, these policy measures were not implemented. Possible explanations include (1) the subject no longer had high priority when the costs appeared lower than expected, (2) the organisers had paid insufficient attention to the perceived problems of parties involved, and (3) changes within the socio-political context. The workshops in which representatives of the policy’s target populations participated did not provide enough interactivity to prevent policy implementation failure.

The Lessons we Learnt: First Outline of Strategy and a Methodical Repertoire for Vision Assessment

As the introductory paper by John Grin put it, this book is about ways to think, as well as on ways to think about thinking, about the future, focusing on the relation between societal problems and technology. In particular, we have focused on the role technology assessment (TA) may play in assessing the visions that are guiding the ways in which actors, in specific sectors, shape their segment of 21st Century society through their collective actions. Specifically, the undertaking reported here was inspired by the suspicion of at least one of us that many so-called revolutionary visions for the 21st Century are, on the level of their basic assumptions, not that different from the visions that have dominated over most of the 20th Century. That is, they too reflect those assumptions that are so typical for High Modernity (see the table in section 4 of that paper). At the core are the assumptions that social progress can be obtained through sound and certain, scientific, knowledge and its application in technology; and that, therefore, society should be guided by institutions that are able to translate such knowledge into courses for action.

A View from the Netherlands: Ethics as Interactive Evaluation

From 1991 to 1994 the Dutch Health Insurance Council financed research on Extracorporeal Membrane Oxygenation (ECMO). This is a technique for providing cardiopulmonary bypass to patients with pulmonary and/or cardiac failure. Most often, these patients are premature neonates. During ECMO, blood is drained from the right atrium, pumped along a membrane where gas exchange takes place, and then redirected to the aorta. To prevent blood clotting, heparin is added. However, with the heparin added, the risk of hemorrhage is considerably increased. Therefore, both the chance of surviving and the chance of severe disability are higher with ECMO than with conventional treatment (i.e., ventilator support).