In this article, we explored how clinical ethicists may employ dialogical CES to support healthcare organizations with developing diversity statements. We argued that by taking a dialogical approach to CES through methods of MCD and the SD in particular, clinical ethicists can foster increased stakeholder participation and thereby promote equity and inclusion in the developmental process. We also provided a case example to illustrate what such a process may look like. Here we will discuss several benefits and challenges clinical ethicists may face when employing dialogical CES to support healthcare organizations with developing diversity statements.

Engaging clinical ethicists to develop diversity statements through dialogical CES has several benefits. As we have argued earlier, dialogue and ethical reflection can stimulate moral learning, foster critical consciousness about diversity issues and traditional healthcare practices, and promote diversity-responsive care (Abma et al. 2009; Abma, Leyerzapf and Landeweer 2016; Denier and Gastmans 2013; Erlen 1998; Frusti, Niesen, and Campion 2003; Kumagai and Lypson 2009; Metselaar et al. 2017; Pratt and DeVries 2018). Also, dialogical CES can increase stakeholder participation, especially given that the democratic imperative and dialectic interaction have been described as two central elements of participatory practice (Springett, Wright, and Roche 2011). Including minoritized and quiet voices in decision-making, policy development and research has been deemed important to stimulate diversity-responsive, inclusive, and equitable practices in healthcare and to facilitate outcomes that have practical relevance and benefit society (Abma et al. 2017a, b; Ghorashi and Sabelis 2013; Frusti, Niesen, and Campion 2003; Seeleman et al. 2015). This means that clinical ethicists can employ dialogical CES not only to increase participation and inclusion as an end in itself, but to support healthcare organizations to develop policies that reflect the needs of those the policies are about, which may increase their practical relevance and social impact.

In our case example, we show one possible way of how clinical ethicists can employ dialogical CES through an explorative Socratic process to develop a diversity statement in a way that includes more voices than traditionally present during a single MCD. In addition to the participants during the dialogical sessions, stakeholders from the work floor and external experts were consulted. While they did not partake in the dialogues themselves, their perspectives and feedback mattered and were reflected upon and incorporated into the final diversity statement. This meant that a variety of additional voices of otherwise potentially “forgotten” stakeholders were heard and included in the dialogical process, thus leading to the development of a diversity statement that represents a variety of relevant perspectives. This makes the Socratic process we described an example of how diversity statements can be developed dialogically and with additional stakeholder participation, other than only those partaking in a specific MCD. This can minimize epistemic injustice by fostering inclusion and improve the content and relatability of diversity statements.

In our case example, we also showed the role clinical ethicists can have in encouraging critical reflection and thereby transforming power relationships, empowering others, and reaching mutual understanding (see also Groot and Abma 2018) to generate a shared perspective on good diversity practices in healthcare organizations. As described by previous authors on participatory research processes: “the role of the ethicists is crucial, supporting reflection on the presuppositions of the interventions and dialogue about the results, either positive or negative. . . . the facilitator acts like a Socratic guide, questioning certainties and taken-for-granted assumptions” (Abma, Voskes, and Widdershoven 2017a, b, 150). By taking a hermeneutic-dialogical approach to CES as described in the case example, the clinical ethicists stimulated critical reflection on the Socratic process, personal judgements, and the “authority” of—for instance—the external experts throughout the SD and Socratic exploration sessions. The dialectic process encouraged participants to question presupposition and gave room to critical voices—particularly on aspects that can hinder the dialogical process or formulation of the diversity statement, like authority concerns.

Finally, including stakeholders that hold positions of power in dialogical CES can also benefit the development and implementation of organizational diversity statements. In our case example, the clinical ethicists collaborated with the director for the elderly care sector who also partook in the dialogical sessions. After the statement was developed, he presented it to the board of directors of the whole organization who eventually chose to adapt the statement as an organizational policy. Pratt and DeVries (2018) previously argued that health equity can be advanced by purposefully structuring deliberations among disadvantaged groups and those in power to change policy. By including the director, who had the power to address and facilitate organizational change, the outcome of the Socratic process found its way to being strategically implemented in organizational policy. The role of the clinical ethicist engaging in dialogical CES to develop diversity statements may thus also include reflecting on who needs to be included to achieve organizational change and implementation.

Despite the benefits of engaging in dialogical CES to develop diversity statements in healthcare, clinical ethicists also face several challenges. We would like to discuss these challenges in relation to our case example, by particularly focusing on concerns related to power dynamics and participation.

First, we must reflect on the role of the clinical ethicist when she is employed by a “client.” In our case example, the clinical ethicists that facilitated the dialogical sessions were recruited and paid by the organization. This client-service provider relationship raises questions regarding the ethicists’ independence and impartiality towards the content and dialogical process. Given as they were hired by the organization, they had an interest in facilitating CES in a way and achieving an outcome that was satisfactory to their employer. This interdependency may signal a power relationship that does not satisfy theoretical, dialogical—and participatory—ideals regarding the (financially) independent role of a clinical ethicist or facilitator in dialogical practice. This is a consideration that is immanent in instances where clinical ethicists facilitate CES with the goal of achieving a practical outcome (like a diversity statement) for a healthcare organization.

Second, another concern pertaining to power disparities in our case example, relates to engaging in CES deliberations among those in power (i.e., a director) and those that are dependent on those in power (i.e., a team manager or a client representative). Other scholars have argued that power differences can affect authenticity, equal participation, inclusion, and social impact and create epistemic injustice by excluding relevant but marginalized voices (Abma et al. 2001; Adler 2012; Boers 2005; Metselaar and Widdershoven 2016; Widdershoven 2001). In his discourse ethics, Habermas (1970, 1973) maintained that coercion- and power-free dialogue is essential to come to valid conclusions and to attain freedom and empowerment through dialogue with a group of interlocutors. Habermas argued that valid conclusions regarding moral obligations can only come about from a coercion-free dialogue (herrschaftsfreie Kommunikation) with all affected stakeholders. This can be achieved through what he describes as an “ideal speech” situation, where discourse occurs on the basis of consensus, inclusion, participation, and democracy (Habermas 1973). However, it may be difficult to apply ideals described in discourse ethics to dialogical practice and to eliminate authority, dependency, and power constraints completely. In our case example, the participation of the director during the Socratic sessions urges the question whether participants experienced complete freedom to be truly honest, open, and authentic about their thoughts and experiences (see also Boghossian 2002). It is possible that participants felt constraints that could have influenced their authenticity and honesty. The threat of authority or perception of power relations caused by the presence of their superior could have caused participations to seek approval and provide answers that they perceive as socially desirable (see also Grill et al. 2015). This may have tainted the dialogical process—a challenge that exists when engaging in dialogical CES that includes individuals with various backgrounds and positions within a hierarchical care organization.

Third, another consideration pertaining to power that is specific to our approach in the case example pertains to consulting an expert panel of researchers on preliminary results of the process. The term “expert” alone could have caused participants to view their feedback as valid, simply due to their perceived authority in the field of diversity. This threatens authenticity and equal contribution. To address this concern, the facilitators clarified during the dialogue that the “expert” voices were not voices of authority but as important as the individual voices present during the dialogue. Additionally, participants openly criticized the experts for having mere “academic expertise,” and argued that other expertise was also necessary for developing a diversity statement that is as inclusive of different voices as possible. This was why it was chosen to include other healthcare professionals in the process too. An important lesson here is that clinical ethicists or bioethics researchers engaging in dialogical CES on diversity issues have an important role to facilitate open communication, reflection, and criticism—especially about issues that may trigger authority-concerns (Abma, Voskes, and Widdershoven 2017a, b).

Rather than providing counterarguments to these reflections on power dynamics, we argue that, due to the inherently hierarchical structure of healthcare organizations and existing social inequities, power relationships will always exist to some extent: even in a dialogical setting. This creates the necessity to address these power issues with participants prior to, during, and after dialogical practice so that power imbalances can, to some degree, be counteracted. Previous scholars involved in participatory health research have made similar observations. Wilkinson et al. (2018) describe that while participatory research may be a more fair and equitable approach to research, we ought to remain “critical of the unresolved challenge of creating research equity. In particular (. . .) of power structures in participatory research . . . ” (1).

If we accept that the removal of power is a regulative ideal rather than being absolutely attainable, then a sufficient dialogical process is not about being able to guarantee the total absence of personal interests and ideal conditions but instead about dealing with and reflecting on them openly during the dialogue (also see Boers 2005; Metselaar and Widdershoven 2016; Metselaar and Widdershoven 2016). Recognizing and reflecting on the position of the clinical ethicists and all those involved in the dialogical CES process is crucial to being aware of positions of power, potential pitfalls, and bad-practices: an argument that has also driven participatory health researchers in striving to address power disparities in healthcare (Groot et al. 2019). This is also indirectly related to Mills’ assertion in “‘Ideal Theory’ as Ideology,” that moral theory—in general—is and ought always be located within the recognition that society and human interactions are shaped by power structures, social privileges, and disadvantages. This means that recognizing the role of systematic oppression and people’s social locations is a crucial first step in refraining from further perpetuating existing injustices and in changing social order. In his words: “one could say epigrammatically that the best way to bring about the ideal is by recognizing the nonideal, and that by assuming the ideal or the near-ideal, one is only guaranteeing the perpetuation of the nonideal” (Mills, 2005, 182).

Another challenge we would like to address relates to the issue of how inclusive and participatory dialogical CES can actually be. The key component of participation is including various stakeholders whilst paying special attention to marginalized voices in order to promote equity and increase the chance for social impact to occur (Abma et al. 2009; Abma, Leyerzapf and Landeweer 2016). In our case example, one may wonder to what degree the participation of marginalized voices was actually achieved. Most participants in the dialogical sessions had the same profession—they were team managers—also most were white women of Dutch descent. However, two client representatives and a policy advisor also participated, and we increased stakeholder participation—as opposed to traditional MCDs for instance—by consulting external experts and other care professionals from the work floor between the dialogical sessions as part of the Socratic process. Nonetheless, our participant make-up raises the question whether the quiet and most marginalized voices within the healthcare organization were sufficiently included. Rather, it is possible to argue that, despite our best efforts, the diversity statement was predominantly produced by those who have done well or fairly well within the bounds of the status quo and that some of the most marginalized remained marginalized from the process of generating the diversity statement, specifically from the three dialogical sessions. This is particularly concerning given our attempt to enhance social justice in the policymaking process and given that patient and community engagement, for example, is decisive in the development of diversity-responsive care and organizational practices—these are often the ones excluded and yet ultimately affected by a given policy or strategy (Seeleman 2015).

In response to this consideration, we would like to stress that this case example is a first exploration of how ethicists may be able to offer support in making healthcare settings more just in practice, by facilitating increased stakeholder participation in the development of a diversity statement through dialogical CES. This example, particularly regarding our participant make-up, is not ideal. Achieving “ideal” stakeholder participation in terms of including all minoritized voices in dialogical CES is a key challenge—and possibly unattainable theoretical ideal—for dialogical and participatory practices, especially in healthcare organizations where hierarchies, power disparities, and limited time and resources exist. However, clinical ethicists ought to continue to strive towards reaching participatory ideals on inclusion as much as possible, particularly when addressing diversity and justice issues. This entails recognizing and critically reflecting on which voices are and which voices are not represented, how this may be remedied, and what this may mean for (the outcome of the) dialogical process. Other clinical ethicists attempting to provide dialogical CES support to develop diversity statements in organizations should critically reflect on ways of expanding and selecting the group of those engaged in formulating a diversity statement, such that it more actively includes those in the organization pushed furthest to the margins, while being extra aware of epistemic injustices.

Furthermore, the main reason that team managers were included in this process was because of their strategic position, standing between healthcare professionals from the work floor and higher management. Their position allowed them to put diversity on the agenda within their teams (also after the statement was developed), to stimulate further dialogical reflection on the diversity statement in practice, and to act as “gatekeepers” that could transfer the voices from others in their teams to the dialogical table. However, we acknowledge that team managers not only hold a position of power but also benefit from material conditions that are not representative for the most marginalized people working for or receiving care in an organization. It is essential for clinical ethicists to reflect on and be aware of the considerations that come with limited and “not ideal” stakeholder participation. This concerns facilitating a deliberation process that aims to be as just and inclusive as possible, while fostering critical awareness on which voices are missing and on the effect this may have, and in developing a diversity statement that recognizes the need for continued dialogue and enhancing diversity-responsiveness and social justice above all.

Finally, we would like to end our discussion with a critical note from Ahmed’s work On Being Included. In her reflection on institutional diversity policies and documents, Ahmed describes that the way these documents are implemented in practice is more important than merely having “an amazing document” with great content that disappears in a drawer and is never seen or used again (Ahmed 2012, 6). She warns of the danger of diversity and equality becoming performance indicators or mere paper trails with little actual effect. Indeed having a diversity statement ought not become a substitute for social action and change. Nonetheless, engaging in dialogue and participatory practices with the intention of developing a diversity statement is a point of departure to foster necessary, recurring, and critical reflection about diversity issues, power, and social injustices. Further, critical dialogue on these topics ought to occur in different ways, with different stakeholders, and at all levels of an organization. However, a diversity statement, even when it is developed on the basis of participatory principles, is not in itself “good” or “sufficient” if it is not used, implemented, and practiced in a way that involves those it concerns and that continues to facilitate awareness, critical reflection, and ongoing dialogue on moral challenges related to diversity and social injustices.