inverse relationship may lead to feelings of powerlessness among patients and may increase uncertainty among physicians. Second, regular medical practices normally don’t call for extra carefulness in the form of a 2nd opinion. This is the case during a PAD assessment procedure, which makes the shared decision making more complex because it introduces another view. The interview study in chapter 5 confirmed that especially psychiatrists that function as an independent expert find this challenging. Third, although guidelines recommend psychiatrists to immediately be transparent about their willingness to perform PAD as soon as a request is made, not all physicians do this. This can lead to disappointment and anger and can complicate the process of shared decision making. Did we use the right methods to find meaningful answers? As described in the general introduction, we set out to use empirical ethical methodologies to gain knowledge about how a psychiatrist deals with the moral challenge of establishing IPS in the context of PAD. Now that the research is completed, it is good to reflect on the empirical ethical methodologies we used. Have they led to appropriate normative conclusions? Empirical ethics is a collective term for different forms of research that use real world experience to guide moral deliberation. Although it is a relatively young field in constant motion, different empirical ethical methods can be distinguished. (Davies, Ives & Dunn, 2015) A useful distinction that is made is between consultative and dialogical approaches. In consultative approaches, stakeholders are engaged, but the ethical analysis takes place afterwards in the research team. In dialogical approaches, the ethical analysis and the conclusions that are made are part of the research encounter itself. Finding consensus or ‘fusing the horizons’ is the goal and acts as an important justification for the normative conclusions. (Davies, Ives & Dunn, 2015) Following this distinction, the empirical ethical work in this dissertation falls into both categories. Although the term ‘empirical ethics’ is traditionally reserved for qualitative methodologies, one might argue that the case report in chapter 2 and the casefile study in chapter 3 are consultative empirical ethical studies. We gathered data in clinical practice and used this as a basis for ethical reflection. Because we did not interact with the study subjects during deliberation these studies follow a consultative approach. Chapter 5 and 6, however, fall into the dialogical category. In the interview study in chapter 5 the participants are explicitly asked about their normative conclusions based on their experience. These experiences and conclusions guided later interviews. The research team also contributed to the analysis by identifying and selecting themes. In the Delphi-study in chapter 6, analysis is part of the research encounter as well. By using different rounds of structured dialogue and by letting the participants learn from each other’s viewpoints, the normative conclusions stem directly from the group of 124 | CHAPTER 7 7