Participatory teaching in bioethics: comments

Persistent efforts have been displayed in proposing a diversity of teaching methods in bioethics, presenting curricula, and pedagogical methods that emphasize active student participation, but are often inapplicable due to limitations of available teaching resources. Scarce financial support, reduced space in curricular programs, insufficient number of well-prepared teachers to tutor small working groups are obstacles to fulfill the needs for adequate training in bioethics. Time and again the Socratic method is hailed as especially appropriate for the teaching of bioethics. The present article intends a critical revision of some participative methods such as the Socratic and Neo-Socratic approaches, as well as casuism and problem solving learning, identifying certain limitations in their usefulness for medical ethics and bioethics teaching. Rather than substituting theoretical teaching, active participation should complement it.


Update
Sociology has claimed that bioethics does not focus on the social problems that require urgent attention, philosophy laments insufficient rigor in its deliberations, anthropology demands a bioethics of the people and not of an abstract "human being"; there is talk of a crisis of bioethics, of its descent into futility, while against all such criticisms bioethics seeks self-assessment through pro domo arguments that close off the path to the revision and correction of its postulates. Objected to from various sides, the cultivation and teaching of bioethics requires reflection in the manner of Pierre Bourdieu, who questions and eventually breaks with some of the fundamental beliefs of the discipline and its pedagogical transmission 1 .
All of the clamorous and chronic discussion about how to teach bioethics revolves around contrasting the value of the expository transmission of theoretical knowledge with accompaniment based on personal tutorials, focused on presenting the problems bioethics faces to students and helping them to deploy the competence to suggest answers with a performative value, which are linked to a fertile relationship between thought and action. The obvious answer is that both forms of teaching must complement each other, but reality demands more precision given the vices that emerge: the chair spreads convictions, principles, dogmas, politically correct truths, and the presumption of the univocity of concepts such as human nature and global ethical values. Bioethics taught by participatory and active methods, on the other hand, is broken down with worrying frequency into deliberative exercises that, while they are motivating and attractive, lack the systematization necessary to develop a tree of bioethical knowledge that allows plausible, coherent and consistent proposals to be reached.
This text reflects on some aspects of the active -participatory -teaching of bioethics, focusing on certain preferred methods such as the Socratic, the Neosocratic, and the Jacotodian approach based on the ignorant schoolmaster, as well as casuist and problem-based learning, to conclude that the uncritical use of these methods may breach their anti-dogmatic purpose, in addition to harboring the risk of a bioethical training deficient in theoretical foundations.

The Socratic method
The Socratic method has been frequently cited as especially suitable for teaching in bioethics 2,3 . The most representative description of this method is found in Plato's first dialogues, which are considered the most faithful to Socrates' thinking, and which in later works have a Platonic imprint that diverges from the Socratic approach.
Texts such as Ion or Euthyphro narrate a conversation between Socrates and an interlocutor, initiating with a question about a moral concept that needs to be recognized through a definition. The answer to the question is unsatisfactory and refuted by a series of additional questions through which Socrates reveals the inconsistencies of the answers. This refutatory or elenchus method invariably accumulates arguments challenged by the logical certainty and irony of the teacher, with the dialogue ending in the impossibility of the correct answer to the initial question being found. The search for the truth always ends in an aporia: a paradoxical and irresolvable false knowledge, something that Socrates seems to have anticipated by striving to create awareness of error and doubt rather than in constructing certainties.
The art of the maieutic attributed to Socrates aimed at students discovering the correct answers for themselves is, rather, an 'obstetrix' of equivocations whose objective is to awaken in students the critical search for prudent and reasonable moral answers to philosophical questions: it is a method that teaches not philosophy but to philosophize. Nietzsche complains of a Socratic rationalism that despises instinct and art, while today it would be said that the episteme does not give space to the doxa 4 .
The methodical refutation that Socrates provides in opposition to the erroneous disquisitions of his interlocutors is a destructive element of the erroneous certainties and vices of thinking. There is some similarity with the Popperian falsification that seeks to destabilize the strength of a generalization and prove its resistance to tolerating exceptions, but in Socrates there is the eagerness of dialectical purification that unmasks false certainties but in no way comes close to proposing certain answers; hence the dialogues end unfinished, as aporia 5 .
Socratic dialogue will only come close to the truth when Plato introduces his own thinking -Platonic realism -and requires reminiscence or anamnesis so that true ideas reemerge in consciousness from a concrete example that allows the formulating of answers to the initial questions.
The other significant contribution of Socrates is loyalty to the Greek aphorism "know thyself", rescued today by Foucault's diligent work around Participatory teaching in bioethics: comments Update the hermeneutics of the self, a subject that has been scantly treated in bioethics and eludes the format of the present article, beyond emphasizing that the advantages of participatory teaching over the passive reception of the discursive-expository theme is that participation involves the student as a person called to self-reflection and communication 6 .

(Neo)socratism
The philosophical work of Leonard Nelson 7 (1882-1927) and his successor Gustav Heckmann 8 (1898-1996) consisted of developing and renewing the Socratic method for school and higher education philosophy teaching. It is noteworthy that both thinkers have a mathematical background and an active political commitment to reinforce and unify socialist ideas, which allows us to understand that their method of teaching has a tendency towards pragmatism, in search of agreement and consensus.
The best known innovation in the renaissance of the Socratic method is Nelson's proposal for re-embedding the dialogical character of the daily lecture in a "group polylogue", composed of a tutor and a small group of students, adopting the method of planting questions and together seeking possible answers 7 . In reality a methodological rather than epistemological Innovation, from which the maieutic is carried out by a group which in a cooperative manner trusts in rational debate to apply selfreflection in order to discover objective truths.
The tutor's job is to order the debate by ensuring the use of understandable and conceptually accepted language, to raise reasonable questions and exchange answers that will be analyzed in groups. In order to comply with the Socratic perspective of perceiving and reflecting on concrete experiences and linking them with general knowledge, Heckmann describes a series of pedagogical requirements to reach valid general conclusions 8 . Among these is the requirement that the teacher must be pre-empted with knowledge and experiences, but must respect the "duty of reticence" not to indoctrinate his or her students or influence their deliberative search.
The development of practical reason through self-directed group work using the "Socratic dialogue" or its variants has been applied in various disciplines, including those dedicated to social work, postulating that this teaching method helps participants to reflect and think in a critical and independent manner, relying on their own abilities to reason and address specific ethical problems 9 . The Socratic group method has had special application in the teaching of philosophy and among pedagogy professionals, having as a critical basis the critical and misnamed "regressive" discourse, which, based on everyday experiences, leads students to analyze more general theoretical postulates.
Truths exist, and it is the instructor's job to guide his or her students in the right way of thinking, which allows them to transform their experiences into certainty. Like Socrates, he or she does not teach philosophy but to philosophize, and instead of failing, tries to reach valid generalities and in this sense, the (Neosocratic) method has the great merit of being antagonistic to dogmatic thinking.

The Socratic Group Method in Medical Ethics
This training method has only been occasionally used in the teaching of applied ethics related to medicine: clinical ethics, bioethics, research bioethics. The German philosopher Dieter Birnbacher 10 (1946) has used his experience in seminars entitled Socratic Group Work in teaching philosophy, postulating the benefits of using the Socratic method in teaching medical ethics, highlighting its attractive aspects: • Ethics is a process and an activity rather than a body of doctrines; • The practice of teaching ethics in small groups; • The rule of taking specific cases as a starting point; • The emphasis on rationality and group argumentation; • Socratic work is a school of freedom, a time for disciplined communication and of principles on difficult and highly emotional topics, with the potential for generalization both for peer-to-peer communication, and empathic, and therefore no less rational, dialogue with individual patients.
Previously, Birnbacher has recognized that he uses the Socratic method with some revisions of the canon: the programs of G. Heckman separate the factual conversation -Sachgespräch -from the "metaphorical" reflection centered on the method rather than the contents discussed -Metagespräch -; Birnbacher, meanwhile, prefers to mix "substantial discussion" with "metadiscussion" which entails the difficulty of abandoning the concrete terrain of the problems and experiences of group reflection, disregarding Nelson's requirement to maintain a constant focus on the central issue under analysis.

Update
Secondly, the role of the tutor must be more than a mere dynamic ordering of the debate, with the potential punishment of being trapped in sterile controversy, adopting a more active role by incorporating in teaching sessions his or her knowledge and competence to encourage the development of new ideas. As a third revision, Birnbacher departs from the goal of reaching consensus, as Nelson required, accepting that consensus is an ambiguous concept and a difficult goal to raise in an environment of tolerant pluralism 11 .
The dilution of the methodical requirements of Nelson and Heckman have become general recommendations that are part of the pedagogical movement towards participatory teaching currently represented by casuistry and problem-solving learning.

The ignorant schoolmaster
The pedagogue Joseph Jacotot (1770-1840) describes his experience in developing learning where both the teacher and his or her students are equally ignorant of the subject to be mastered, reinforcing the idea that all intelligences are equally apt for learning; his concept of universal education was aimed at emancipating intelligences 12 . Traditional methods of education are based on inequality between those educating and those being educated; the transmission of knowledge has among its objectives the signaling of the inequality between the person who knows and the person who is learning, the expert and the student.
Participatory education is based on the equality of intelligences, as Jacotot argued, the political objective of emancipating the stupefied as Rancière 13 writes, in convergence with the liberating literacy that Paulo Freire describes and practices in his writings, mainly in "Pedagogy Of The Oppressed" 14 .
In both Rancière and Freire the pedagogical interest converges with the political commitment of justice.
The ignorance of the schoolmaster, simulated in Socrates and real in Jacotot, is a fiction that is opposed to the pedagogical need to transmit knowledge. It is to be remembered that the Latin root docere gave rise to teacher (docent), but also to doctrine and docile, all words that are collected in the traditional schoolmaster based class. Despite proclaiming that he only knew that he knew nothing, Socrates did not place himself on the same level of ignorance as his disciples, on the contrary, he brandished his rhetorical ability to overthrow the arguments presented, using the analogy and irony that have been strongly criticized by followers of the ignorant schoolmaster doctrine:

Casuistry
Traditional casuistry is based on the study of a singular case to determine if it conforms or violates maximum precepts held as immovable. Its maxims are dogmas, while the cases are particular situations subject to biased interpretation to show that the case under trial violates the established maximums, as was practiced in the abusive extremes of casuistry by the medieval Inquisition.
A renewed casuistry as a procedure to clarify bioethical situations was presented by Jonsen and Toulmin 16 , indicating how the core activities of the method consist of the designation of themes, the interpretation of maxims and principles in the light of circumstances, and the use of analog reasoning. It is possible that these stages are subject to easy misunderstandings since the description of topics, the choice of appropriate analogies and the description of circumstances can be subjective and discretionary, or altered by cultural prejudices 17 .
Attempts are made to avoid these difficulties by making paradigmatic cases or, returning to premodern casuistry, the acceptance of apodicts, or another similar attempt to base the study of cases on accepted generalities. However, the objection of Kenneth Wildes 18 , s.j. is noteworthy, pointing out that in modern, secular and multicultural society, there are no maximums with a prescriptive force that serve as a reference framework for case analysis.
Initial attempts at Georgetown's principlism have had to accept their prima facie status, subject to justification, specification and prioritization, which makes them insufficient as a frame of reference for casuistry: there is no clear logical priority that could be assigned to the principles or case analysis [classjudgments]; the relationship between the two is better understood as dialectic, since neither by itself derives from the other but each potentially modifies the other 19 .

Problem solving learning
Faced with the evidence that professional ethics should be reinforced, the use of supported problem solving, especially in medicine, such as case studies, appears to be an ideal approach. The student actively participates in the debate and in the search for answers to the problem posed, while at the same time this pedagogical exercise helps him in "defining his identity". A brief but seminal article recommends Problem Based Learning (PBL), developing two concepts that distance this from the Socratic method. First, it argues that the teaching of an ethics applied through problem solving must be reinforced with carefully selected readings. Secondly, the teacher, far from being ignorant or appearing so, must have an adequate knowledge of moral philosophy 20 .
The method of problem solving would be more effective if the knowledge base and the application of that knowledge were the primary principles of theory and practice… in addition to teaching students sound teaching skills, teach them what knowledge has been successful at solving the problems in the past and why 21 .
Endless discussions revolving around perhaps clarifying active teaching based on problems or whether particular cases are inductive in character brings empirical experience to the formulation of generalities -or is deductive -allowing the ordering of the particular in accepted moral generalities. The response has been eclectic, favoring 'coherentism': neither general principles nor particular circumstances have sufficient power to generate conclusions with the needed reality. Principles need to be made specific for cases, and case analysis requires illumination from general principles 22 .
The weakness of the study of problems and bioethical cases lies in the difficulty of relating the particular to the general, to ensure that the study of the singular situation is not exhausted through minute analysis, but that it conforms to certain general moral norms that are accepted in any human community 23 . A case of idiosyncratic resolution born from particular analysis could be justified if it is accepted that it will be submitted to public scrutiny and can convince that in similar circumstances it could be legitimate to make decisions in the same way 24 . This is a very diluted version of the Kantian categorical imperative, but it must be respected to avoid particularism and unpredictability. Both coherentism and the recourse to a "common moral" illustrate that bioethical deliberation requires a theoretical structure that must be explicitly taught along with active exercises of the deliberation of cases and problems.

Didactics in bioethics
From the last third of the previous century, Latin American universities have begun to introduce reforms in the teaching of medicine, with greater emphasis on social and community aspects. By including bioethics in the compulsory medical curriculum, an active debate was opened on how ethics in general, and applied ethics in particular, can best be taught 25 .
There are good reasons to distinguish the training process in bioethics from that applied in other disciplines of knowledge, even in ethics applied to other social practices that can be framed in a formal professional deontology, which in bioethics is impossible when the dynamics of the task is subject to deliberation and not codification. The teaching of bioethics in the region requires practical-theoretical complementation and curricular specification based on its reality. The doctor-patient relationship, for example, requires its own bioethical reflection as it can occur in a mostly private health system -the USA -a universally public one -Europe -or economically precarious situations, as occur in nations with scarce and insufficient resources.
Teaching bioethics must provide theoretical foundations and the deliberation of values; in accordance with pedagogical modernizations, active learning must take precedence over the obsolete master-based class that produces passive, superficial reception and which has little impact on the knowledge and action of the students, focused on the work of small groups that facilitate interlocution and the active participation of all, without neglecting the transfer of knowledge through relevant readings or systematic interventions by the tutor. There are no major disputes about this pedagogical desideratum, but the teaching of bioethics at all levels continues to deliver unsatisfactory results, for at least three reasons: • The uncritical and prioritized adoption of participatory methods without recognizing their ancillary and complementary nature to a solid theoretical training of both teachers and students. The application of didactic methods used in philosophy and mathematics -Socratic and Neosocratic -or which have been developed for the purpose of emancipation and equality -Jacotot, Rancière, Freire -requires still awaited adaptations to bioethical language; • The need for an integrative Latin American bioethics based on two vectors: the common confrontation of serious conflicts generated by a growing inequity in health, biomedical research and ecological issues, caused by processes such as medicalization, commercialization, depersonalization and other social ills, requiring its own regional voice but participating in the cultural debate of the mainstream bioethics, displaying a different form of integration of finer material than the "simultaneous paradoxical bioethics" that has been proposed for the region 27 . Our students should know and discuss seminal publications of the Transregional bioethics to develop a proper and attentive voice that critically deliberates with and about the foreign, avoiding excessive permeability to alien programs and proposals.
The second integrating vector consists of displaying a more uniform and common regional bioethical language, encouraged by certain agreements in the teaching methods and contents. More than the North/South polarization, the ideological distinction according to levels of development, or the most recent categorization according to macroeconomic indicators, we share historical processes and common socio-cultural realities, definable as Nations with Limited and Insufficient Empowerment (or Nelis).
The indifference to cultivating a Latin American voice that is both of its own and common, but not completely disconnected from the debates that take place in other latitudes, puts us in a vulnerable situation when faced with the lack of protection against the globalizing influences that bioethics should criticize and alleviate: the privatization of medicine, the impact of the pharmaceutical industry on lines of research that disagree with local needs and the invasion of the market by prohibitively priced products, as well as the unstoppable technoscientific medicalization of middle -or lowincome societies, contributing to inequalities in health provision aggravated by insufficient fiscal budgets. The reduced influence of regional bioethics in international document reviews (Helsinki, Cioms) is another warning call to seek minimum agreements and some degree of uniformity in bioethics training at all educational levels.

Discussion
Deliberation in areas such as ethics, where rationality is accompanied by faith-based convictions, accepts the presentation of epistemic arguments -cognitive -as well as doxastic approaches -of beliefs and opinions -combining what Max Weber called rationality of ends -Zweckrationalitätand rationality of values -Wertrationalität. The deployment of an applied ethics and its use in practical situations, is constructed from a double aspect: "ethical-normative reflection (eventually metaphysical)" and "scientific information" 28 . This coincides with the requirement of homogeneity as set of basic knowledge that cannot be omitted, a common denominator among all members of the teaching team 29 .
A bioethicist has to be a moral philosopher because he or she seeks ethical certainties, plausible arguments, reasonable agreements and is against everything that is wrongly misleading and should tend to radiate that thought, both verbally and attitudinally (…) Bioethics resists all bad, negative actions, such as abortion, euthanasia, stealing, murder, etc. And on a professional level it supports the truth, civil responsibility, justice, acting according to the profession -following the ethical codes -and to his or her vocation 30 .
If the teaching of bioethics is not this, to put it in a polite, satisfactory manner, it will be necessary to review it from various sides, some of them outlined here, from the questioning reflection of Bourdieu and Walter Benjamin's proposal to demolish to rebuild, to a suggestion of "ethical unlearning" 31 , which are various ways of exercising the critical theory that questions the current in order to propose modifications. The reconstruction is not ab ovo, since the demolition provides material for new concepts that must be embedded in an existing disciplinary structure, either to refute, modify or confirm its constituent elements.
The purely descriptive presentation of bioethical issues is a monologue that does not stimulate criticism or debate, and therefore there is no bioethical growth. Aware of this, active teaching Participatory teaching in bioethics: comments Update has gone to the opposite extreme of disregarding the theory, boasting of ignorance, and disregarding the need for the bioethics teacher to have a solid background that he or she must share with his or her students to systematize the findings of the active participation sessions. Practice teaches that this active participation of the students quickly loses the central thread of the topic to be considered, unless they have received and read some theoretical material in which to sustain the debate. The tutor should not be ignorant or pretend to be; on the contrary, he or she must be what W. Kohan calls an explanatory teacher, engaged in a more active and fertilizing role than a reprobative maieutic method 32 .

Final considerations
Participatory teaching is the fundamental trunk of bioethics teaching, although compliance is usually limited by a lack of resources and a fragile institutional will bent before utilitarian requirements. Active participation, emancipation, liberation, equality and respect for a legitimate pluralism, are hindered by the fragmentation of courses in larger groups than is desirable, deliberation inhibited by restricted curricular spaces. Contextual obstacles that force sub-optimal solutions result in the persistence of master-based classes and lectures before large audiences.
The most used active teaching approaches contain deficiencies and inadequacies that do not recommend their application in a schematically pure manner, forgetting that they are complements to a theoretical systematization that should accompany them closely. The curricular plan that puts the theoretical subjects of the early years far from the practical application phase, into which we have all fallen, would be more effective if it integrated theory and practice more closely. Instead of a permanent tutor for each group, there would ideally be a rotation of teachers, in order to respect the pluralism that bioethics requires.