Skip to main content Accessibility help


  • Bjørn Hofmann (a1), Sigrid Droste (a2), Wija Oortwijn (a3), Irina Cleemput (a4) and Dario Sacchini (a5)...


Background: Ethics has been part of health technology assessment (HTA) from its beginning in the 1970s, and is currently part of HTA definitions. Several methods in ethics have been used in HTA. Some approaches have been developed especially for HTA, such as the Socratic approach, which has been used for a wide range of health technologies. The Socratic approach is used in several ways, and there is a need for harmonization to promote its usability and the transferability of its results. Accordingly, the objective of this study was to stimulate experts in ethics and HTA to revise the Socratic approach.

Methods: Based on the current literature and experiences in applying methods in ethics, a panel of ethics experts involved in HTA critically analyzed the limitations of the Socratic approach during a face-to-face workshop. On the basis of this analysis a revision of the Socratic approach was agreed on after deliberation in several rounds through e-mail correspondence.

Results: Several limitations with the Socratic approach are identified and addressed in the revised version which consists of a procedure of six steps, 7 main questions and thirty-three explanatory and guiding questions. The revised approach has a broader scope and provides more guidance than its predecessor. Methods for information retrieval have been elaborated.

Conclusion: The presented revision of the Socratic approach is the result of a joint effort of experts in the field of ethics and HTA. Consensus is reached in the expert panel on an approach that is considered to be more clear, comprehensive, and applicable for addressing ethical issues in HTA.



Hide All
1. Office of Technology Assessment. Development of medical technology: Opportunities for assessment. Washington, DC: Office of Technology Assessment; 1976.
2. Burls, A, Caron, L, Langavant, GC, et al. Tackling ethical issues in health technology assessment: A proposed framework. Int J Technol Assess Health Care. 2011;27:230237.
3. Droste, S, Dintsios, CM, Gerber, A, Rüther, A. Integrating ethical issues in HTAs: More methods than applications? In: HTAi 7th Annual Meeting Dublin 2010. Maximizing the value of HTA. Book of Abstracts; Dublin: 2010;M5-02:169.
4. Hofmann, B. Toward a procedure for integrating moral issues in health technology assessment. Int J Technol Assess Health Care. 2005;21:312318.
5. Saarni, S, Braunack-Mayer, A, Hofmann, B, van der Wilt, GJ. Different methods for ethical analysis in health technology assessment: An empirical study. Int J Technol Assess Health Care. 2011;27:305312.
6. Saarni, SI, Hofmann, B, Lampe, K, et al. Ethical analysis to improve decision-making on health technologies. Bull World Health Organ. 2008;86:617623.
7. DeJean, D, Giacomini, M, Schwartz, L, Miller, FA. Ethics in Canadian health technology assessment: A descriptive review. Int J Technol Assess Health Care. 2009;25:463469.
8. Droste, S, Gerhardus, A, Kollek, R. [Methods for the assessment of ethical aspects and moral concepts in society in short HTA reports an international survey]. Niebüll: Medicombooks; 2003.
9. Hofmann, B. Why ethics should be part of health technology assessment. Int J Technol Assess Health Care. 2008;24:423429.
10. Lehoux, P, Williams-Jones, B. Mapping the integration of social and ethical issues in health technology assessment. Int J Technol Assess Health Care. 2007;23:916.
11. Ten Have, H. Ethical perspectives on health technology assessment. Int J Technol Assess Health Care. 2004;20:7176.
12. Hofmann, B. On value-judgements and ethics in health technology assessment. Poiesis Prax. 2005;3:277295.
13. Brinch, B, Husebekk, A, Funderud, S, Lyngstadaas, A. Therapeutic use of haematopoietic stem cells from cord blood. Oslo: SMM-rapport No. 4/2003.
14. Droste, S, Herrmann-Frank, A, Scheibler, F, Krones, T. Ethical issues in autologous stem cell transplantation (ASCT) in advanced breast cancer: A systematic literature review. BMC Med Ethics. 2011;12:6.
15. UK National Screening Committee [Internet]. London: Criteria for appraising the viability, effectiveness and appropriateness of a screening programme [cited 2012 Aug 12]. (Accessed, July 1, 2012).
16. Hofmann, B. Etikk i vurdering av helsetiltak [Ethics in Health Technology Assessments (HTA)] Oslo: Norwegian Knowledge Centre for the Health Services; 2008.
17. Centre for Reviews and Dissemination. Systematic reviews: CRD's guidance for undertaking reviews in health care. York: CRD, University of York; 2009.
18. McCullough, LB, Coverdale, JH, Chervenak, FA. Constructing a systematic review for argument-based clinical ethics literature: The example of concealed medications. J Med Philos. 2007;32:6576.
19. Sofaer, N, Strech, D. The need for systematic reviews of reasons. Bioethics. 2012;26:315328.
20. Strech, D, Sofaer, N. How to write a systematic review of reasons. J Med Ethics. 2012;38:121126.
21. Hannes, K, Lockwood, C, Pearson, A. A comparative analysis of three online appraisal instruments’ ability to assess validity in qualitative research. Qual Health Res. 2010;20:17361743.
22. Oortwijn, WJ. First things first: Priority setting for Health Technology Assessment [Dissertation]. Leiden: De Bink BV; 2000.
23. Ministerie, VWS. Acht nieuwe geneesmiddelen toegelaten tot het ziekenfondspakket (12 April 2000, nr. 38). Den Haag: Ministerie van Volksgezondheid, Welzijn en Sport; 2000.
24. Stolk, EA, Brouwer WBF, Busschbach JJV. Vergoeding van Viagra stuit op waarden en normen. Medisch Contact. [Internet]. 2002 May [cited 2012 July 7]; 55(17):. (accessed, July 1, 2012)
25. Daniels, N, Sabin, J. Limits to health care: Fair procedures, democratic deliberation, and the legitimacy problem for insurers. Philos Public Aff. 1997;26:303350.


Type Description Title
Supplementary materials

Hofmann Supplementary Material
Supplementary Material

 Word (40 KB)
40 KB


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed