Practising reflexivity: Ethics,methodology and theory construction

Abstract

Reflexivity as a concept and practice is widely recognized and acknowledged in qualitative social science research. In this article, through an account of the ‘reflexive moments’ I encountered during my doctoral research, which employed critical theory perspective and constructivist grounded theory methodology, I elaborate how ethics, methodology and theory construction are intertwined. Further, I dwell on the significance of reflexivity, particularly in qualitative research analysing bioethics concepts. Through an account of the universal ethical principles that ‘I’, as a researcher, encounter, and a micro-analysis of the observed relationships that influence the theoretical construction and arguments developed, I explore the quandaries an ethics researcher undertaking a reflexive approach faces. I elucidate that reflexivity unveils – for both researcher and reader – how the researcher(s) arrive(s) at certain positions during the knowledge construction process. I conclude by stating that reflexivity demystifies the moral and epistemological stances of both the study and researcher(s).

Manifestation of reflexivities

The concept of ‘reflexivity’ has been central to academic discussions of knowledge production for many decades (Charmaz, 2006; Charmaz and Mitchell, 1996; D’Cruz et al., 2007; Etherington, 2004; Finlay and Gough, 2008; Gergen and Gergen, 1991; Hammersley and Atkinson, 2007). In academic theses and articles it has become a ‘ritual’ to include an explicit discussion of the researcher’s positionality and its influence on the research. Reflexivity is intended to function as an evaluating scale which ‘measures’ the quality and rigour of qualitative research (Cohen and Crabtree, 2008; Hall and Callery, 2001; Jootun et al., 2009; Koch and Harrington, 1998; Sandelowski, 1993). It has transformed the question of subjectivity in research from a problem to an opportunity and has been conceptualized from various perspectives within diverse disciplines and studies which acknowledge its influence on the research process (Finlay, 1998; Finlay and Gough, 2008; Gentles et al., 2014; Guillemin and Gillam, 2004; Pillow, 2003; Stronach et al., 2007). Of late, the concept of reflexivity and its importance has gained significance within the field of bioethics research also (Corrigan, 2003; Dunn and Ives, 2009; Hedgecoe, 2004; Ives, 2014; Ives and Dunn, 2010). While the need for reflexivity in qualitative studies has long been acknowledged, in the recent years there has been an increasing focus on the question of how to practise reflexivity (Etherington, 2004; Finlay and Gough, 2008; Ives and Dunn, 2010). Researchers employ reflexivity in their research by drawing on different traditions, and there have been diverse variants of reflexivity (Finlay, 2002; Finlay and Gough, 2008; Hertz, 1996; Mauthner and Doucet, 2003; Neill, 2006; Pillow, 2003). While providing an account of different variants of ‘reflexivity’, Finlay and Gough (2008) acknowledge the blurred borders among the variants and the overlaps. Within these diverse forms of ‘reflexivities’ one can identify how reflexivity is practised and adopted: who practises ‘it’; what the research is ‘on’; and what the researcher’s agenda ‘is’. Each researcher embarks on their reflexive journey by giving significance to what they think is crucial to their research (Bradbury-Jones, 2007; Carter and Little, 2007; Damsa and Ugelvik, 2017; Guillemin and Gillam, 2004; Hammersley and Atkinson, 2007). Many have argued that it is inevitable, and essential, for researchers to be self-reflexive (Etherington, 2004; Finlay, 1998; Hertz, 1996; Lumsden, 2013; Lynch, 2000; Venkatesh, 2013; Walsh, 2003). Reflexivity has also been argued to be a methodological tool to account for the situated and embodied nature of knowledge production (Etherington, 2004; Le Grand, 2014; Pillow, 2003). Instead of labelling the different variations of ‘reflexivity’ and discussing them within the narrow boundaries of each variation, I illustrate my own journey of reflexive research through certain ‘reflexive moments’ – significant experiences and reflections at certain stages of research which helped me reconstruct the research journey in a better way. By doing this, I offer a discussion of how the reflexive approach was understood and employed in the process of my doctoral research; how it helped in knowledge production; and how I experienced reflexivity and navigated through various phases of my research.

This article is a result of my epistemological and methodological stance of employing a reflexive approach in my doctoral research and consciously treating reflexivity as a practice of doing research rather than an academic virtue or source of authority over knowledge. I argue that examining ethics or the moral concepts in ethics research requires a critical and reflexive approach towards one’s moral, epistemological positions and their influence on research. I focus on the ripple effect of reflexivity within constructivist grounded theory (CGT) methodology combined with a critical theoretical paradigm and present the ethical quandaries in the relationships between the researched and the settings, as well as within ‘oneself’ as a researcher. In my doctoral research, I adopted a broad contextualized approach to examine the ethical principles or values of the concept of ‘informed consent’ in clinical practice within elective clinical surgery and court judgements in consent cases of medical negligence in the Indian context. Examining the ethical principles or values of a concept like ‘informed consent’ involves understanding the moral values, beliefs, assumptions and practices of individuals, institutions and social context. In the context of the ‘empirical turn’ in bioethics research, I highlight the significance of reflexivity, and offer an account of practising reflexivity. I present my reflections based on my observations and in-depth interviews conducted as part of my doctoral research at hospital settings (government and private) during the period February 2016 to July 2017 in Chennai, a metropolitan city in south India. The study was conducted after obtaining approval from the Ethics Committees of both hospitals. The research involved a total of 63 in-depth interviews with patients and family members, surgeons and nurses; and observations during data collection at the in-patient wards, corridors, lawns, parks, canteens and waiting rooms.

I have structured this article interlocking personal, methodological, and theoretical reflexivity. I have divided the article into three parts. In the first, I offer a narrative of my own practice of reflexivity, or rather how I ‘encountered reflexivity’ during the course of my research. I present my research journey in the form of a confession tale (Van Maanen, 2011) as it plays a significant role in construction and co-construction of knowledge. While I am aware that, I am acknowledging authority over my research by employing reflexive approach, I believe that it is important to be aware of and reflect on the knowledge construction process while doing research where we have epistemic authority and responsibility. Here I provide only a partial picture, through a discussion of certain ‘reflexive moments’. However, it does not mean that other moments are insignificant (O’Reilly, 2012). It is me, the researcher, who designates certain moments as ‘reflexive moments’ based on the recurring significance of the experience in my journey, both past and present. In the second part of the article I discuss how taking a reflexive approach has influenced my epistemological and methodological stances. I discuss particular reflexive moments which present my thoughts, ethical quandaries, and relationships while carrying out critical CGT research and the influence these moments have had in directing and constructing moral and theoretical arguments. Finally, I briefly discuss the significance of reflexivity within qualitative bioethics research.

Reflecting on the journey: when did reflexivity start to matter?

The moment of self-awareness happened in my journey as a qualitative researcher when I was a research associate in a project studying patient autonomy in the Indian context. ‘Something’, for which I did not yet have a name, started bothering me while I was engaged in field work, interviewing general physicians on patient autonomy. The process of listening to doctors, while conducting interviews for the project, made me reflect on my own experience as a patient as well as a caretaker in hospital settings. My personal experiences within medical institutions influenced the nature of the interview guide and questions. This left me pondering over the following questions: should my personal stories or experiences influence the way I conduct research?; and would taking such an approach not affect the methodology and theoretical direction? As I was part of a team which had members with diverse epistemological and methodological positions, I could not engage in reflexivity while undertaking that project. However, when I joined the doctoral programme, after completing the project, the questions that arose in my mind during the earlier fieldwork resurfaced. These questions, along with my central research questions on the concept of ‘informed consent’, continued to disturb me. While identifying a particular methodological approach for the study, my epistemological inclinations directed me towards CGT methodology (Charmaz, 2006, 2008, 2011). As CGT acknowledges a researcher’s experience and encourages reflexivity, I consciously started practising reflexivity during the research process.

Past and present: personal stories and research questions

In the later part of this article, I provide an account of the reflexive moments and experiences I encountered during my research. At this stage, it is important to provide some details on my socio-economic and geographical location to situate my-self, and my arguments. I was raised in a lower middle class, non-upper caste Hindu family in a semi-urban area. I have chosen the self-description ‘non-upper caste’ instead of stating whether I belong to an intermediate caste, or a lower caste, as my personal experiences do not neatly fit into any of these categories. Put differently, I was raised in a household which struggled financially, one that could not afford ‘good’ schools or colleges. We did not spend weekends in malls or cinemas or take summer vacations, which were all seen as ‘urban childhood dreams’. While growing up, all I aspired to was to earn a comfortable income and save some money to take care of my family. I am a cis-gendered female who grew up in the outskirts of Bangalore, without much exposure to or awareness of exploring other sexualities. Now I live in the heart of the city of Chennai, a metropolitan city in south India where I have access to contemporary arts, culture and opportunities to be part of political debates. I have had the privilege to pursue doctoral research in one of the elite institutes of India. I have indeed benefitted from privileges associated with my gender, class, caste and opportunities to reach this position, though it involved diverse negotiations within both academic and social spaces. As is the case with anyone else, I too can be considered both privileged and underprivileged, depending on the context and parameters.

Reflecting on my stories/experiences

To understand a researcher’s relationship with social structures and institutions, it is important to explore his or her personal stories/histories (Kanpol, 1997). We play diverse roles in our lives – mother, sister, daughter, friend, citizen, government servant, etc. During the course of my research, the major recurring roles I had to reflect on were those of ‘patient’ and ‘caretaker’ within the Indian healthcare system. As mentioned earlier, during my research in the field of medical ethics, along with exposure to critical theoretical literature and ethical theories, my experience as a patient and a caretaker has had immense impact on my reflexive thoughts. In what follows, I offer an account of certain experiences, with a reflection on each role. This is followed by an account of how these reflections influenced my research questions and perspectives.

Medical institutions and stakeholders significantly influence the experience of being a ‘patient’ and ‘caretaker’. There were multiple instances when I was either a ‘patient’ or a ‘caretaker’. However, here I narrate a few of my encounters with healthcare professionals and the healthcare system. Since being a ‘patient’ and a ‘caretaker’ play a significant role in our reflexive position, a reflexive account of my experiences can provide a lens for understanding the research questions of my study. On being diagnosed with Polycystic Ovarian Disease (PCOD), I visited a doctor in a government hospital in Chennai for further consultation. I had read some articles on PCOD prior to the meeting with the doctor. I asked the doctor certain questions about my health condition. She gave very little information about the issue and treatments available; the more I inquired, the more she became annoyed, and showed her reluctance to engage in a conversation. Her expression seemed to convey to me: ‘How dare you question me?’ and ‘Don’t irritate me with “stupid” questions’. She asked me in an evidently irritated tone, ‘Is it Dr. Google that you trust?’ She prescribed me some medicines and quite authoritatively told me just to take those medicines and continued to give instructions on the dosage and so on. Overall, I felt rushed by the doctor and felt that there was very limited space for me, as a patient, to communicate with her. I was left with an authoritative order that demanded that I accept her within the given medical setting and health care system. The other incident which I recall was when I was a ‘caretaker’ in a partially government funded private hospital in Bangalore. My father had to undergo coronary angioplasty and I was the one taking care of paying the bills, interacting with the doctors and nurses and other administrative errands. My mother and I would anxiously try to approach the doctors and nurses to get updates on my father’s health. However, the hospital staff seemed to avoid interactions, gave curt replies without divulging too many details or would avoid answering altogether, all the while maintaining a strong power distance.

When I discussed my initial research proposal on ‘informed consent’ and my own experiences with friends and colleagues, they too recalled similar instances. Sharing my experiences and listening to others’ experiences became part of my research journey. A recurrent theme that emerged in these narratives was that of doctors being authoritative and powerful, on account of their knowledge, skills and their privileged roles. Further, through reading various studies, I came to the understanding that it is not just doctors who come across as authoritative, but that medicine itself as a system perpetuates certain power structures and hierarchies (Foucault, 1973; Gutting, 2005; Jones and Porter, 2002; Lindenbaum and Lock, 1993; Lupton, 2012). I also recognized that the socio-political context in a particular society plays a significant role in shaping the individuals in that society (Annandale, 1998; Nettleton, 2006). Some of the questions that emerged in this context are as follows. Does every communication in the relationship between the doctor and the patient or the caretaker have some element of dominance? Do patients trust doctors and why? Do they consent to surgery because of trust, authority, autonomy or simply as a ritual? Which values will be preferred when the patient is a consumer or a client? How does Indian medical law understand the meaning of doctor–patient relationship and informed consent? Do doctors provide material information on alternative choices of treatment and discuss risks? If not, why? These questions that emerged out of my personal experiences and experiences during my earlier fieldwork heavily influenced the research questions for my doctoral research. It is from them that I finally arrived at the following research objectives for my doctoral research:

• To explore the meaning of ‘informed consent’ among surgeons, nurses, patients, and family members’ within hospital settings, and

• To examine the ethical and legal principles or values of ‘informed consent’ in the Indian context.

• I wanted to show the relationship between the personal experiences of the researcher (i.e. me) and its influence on the research questions and the underlying analytical framework researchers adopts to build their theoretical arguments.

Reflexivity on epistemological and methodological stances

Given the kind of experiences I had encountered at both public and private hospitals and my reflections on these, I decided to undertake research on how the concept of reflexivity was understood in both types of institutions. I also wanted to explore if there was any difference in the understanding and implementation of the concept of ‘informed consent’ due to differences in institutional structures and power dynamics. Further, based on my analysis within the realm of judiciary, I realized that the concept of ‘informed consent’ is consciously sidelined by the Indian judiciary in favour of the concept of ‘real or valid consent’ (Subramani, 2017). This analysis provided me with a further critical lens to understand the concept studied within the field of law and in clinical practice. As mentioned earlier, CGT acknowledges researchers’ experiences and interpretations and provides space for discussion from a critical perspective, a concern I was preoccupied with in my study (Charmaz, 2006, 2011, 2017). Kathy Charmaz’s work on grounded theory methodology significantly influenced the theoretical framework and approach of my doctoral research. I argue that ‘consent’ is a process which has to be understood within the subjective meanings of constructed reality, and not as a process within an ‘objective world’. Within a positivist framework, researchers focus on an objective understanding of informed consent, and there is no room for constructed knowledge as perceived by the researcher and the researched. I believe that aiming for objective truth fails to capture the rich complexities of our lived experiences and their assigned meaning, leading to a failure in adequately understanding the concepts or the phenomenon (Birks and Mills, 2011; Clark et al., 1991; Charmaz, 2006, 2011; Mills et al., 2006). Since the aim was to explore the meaning of the concept of ‘informed consent’ and its’ underlying ethical principles or values in the Indian context, the constructivist approach, rather than a positivist one, was an apt framework. I found Charmaz’s CGT as the appropriate methodology to address my research questions. I adopted Charmaz’s theoretical stance of constructivism, which, according to her, is ‘a social scientific perspective that addresses how realities are made’. Thus,

… this perspective assumes that people, including researchers, construct the realities in which they participate. Constructivist inquiry starts with the experience and asks how members construct it. To the best of their ability, constructivists enter the phenomenon, gain multiple views of it, and locate it in its web of connections and constraints. Constructivists acknowledge that their interpretation of the studied phenomenon is itself a construction. (Charmaz, 2006, p. 187)

I situated my research within a critical theoretical perspective, which identifies and gives significance to the social institutions and power differences which shape the meanings that people experience and live with (Gergen, 1999; Hacking, 1999; Holstein and Gubrium, 2008). Consequently, I adopted constructivism and critical theory as my epistemological and theoretical perspectives because I believed these could help me rethink my/our perceived social reality and question the current practices (Blumer, 1986; Bryant and Charmaz, 2007; Charmaz, 2011). From the relativist epistemological stance that CGT adopts, I believe that there are multiple constructed social realities and participants, researchers, and their experiences are part of the process of constructing meanings (Charmaz, 2000, 2006, 2011, 2017). This approach illuminates the researcher’s position and their contribution and critically engages with concepts and helps researchers to scrutinize their actions within the research settings and context (Charmaz, 2006, 2015). By being reflexive to the methodology I had intuitively adopted owing to my constructivist proclivity, I was attentive to the claims of relativism that CGT may evoke within moral knowledge debates. From a relativist epistemological stance, I believe that how we construct understandings from the experiences and how meanings are shaped in research, ultimately constructs the theoretical and moral conclusions and arguments of the concept studied. In my study, I have attempted to analyse the ethical principles or values of the concept of ‘real or valid consent’. Hence the reflexive understanding of the influence that relativist epistemological stance and CGT have on examining the underlying ethical values or principles helped me identify both its appropriateness and limit. For instance, I asked whether findings and analysis of constructed understanding alone can decide the ‘ethical’ value which needs to be endorsed in the context of the study. Critical reflection on this question leads to moral epistemological questions, which I, as a qualitative ethics researcher, have been grappling with. While my focus is on identifying and examining the concept of ‘consent’, on reflecting upon my methodology I strongly believe that it should not result in my arguments being located or contextualized and labelled under ‘cultural relativism or ethical/moral relativism’. In short, the fact that concepts and meanings are constructed within particular contexts should not stop us from questioning the values attached to the concept within a particular context. I adopt this methodology to provide an account of the constructed meanings and take further steps to question the existing practices by inclining towards a meta-ethical position of ethical universal framework (Buss, 1999; Darwall, 1977, 2006; Entwistle and Watt, 2013; Hill, 1991; Macklin, 1999; O’Neill, 1998). In my study I attribute significance to the constructed meanings of the concept of ‘consent’, but at the same time critically analyse the moral concepts and ethical principles which are at stake and then identify the particular ethical value which I endorse and justify it in my theoretical arguments. Practising reflexivity within the critical theory perspective and CGT on the process of identifying the ethical principles or values demystify the moral epistemological claims which qualitative ethics research brings. However, it also opens up further challenges of larger moral epistemological issues such as: does reflexivity questions objective moral truths? Is there moral reality or truths? How can a researcher attain it? Though these questions are discussed in larger moral philosophy and meta-ethics, within bioethics one should dwell on the questions of ‘moral knowledge’ as different researchers take different epistemological stances in research while arriving at moral and normative conclusions.

Practising reflexivity: intersection of methods, methodology, theory and moral arguments

There are quite a few studies which address the question of how to be reflexive and how to practise reflexivity (Berger, 2015; Doucet and Mauthner, 2002; Engward and Davis, 2015; Guillemin and Gillam, 2004; Hertz, 1996; Ives, 2014; Mauthner and Doucet, 2003). Some of these studies adopt the practical model developed by Alvesson and Sköldberg (2004) to be considered in research (Engward and Davis, 2015). While this model would help the researcher to reflect methodically, I believe that it is of paramount importance for any researcher to be conscious of the suggested reflexive steps. Rather than following the principle of reflexivity methodically, in this article I attempt to capture certain ‘reflexive moments’ during my research and to illustrate through these experiences the intertwining relationship of method, ethics and construction of theoretical or moral arguments. As mentioned earlier, my research questions and approach were shaped by my personal, theoretical and epistemological stances. I have drawn my understanding of the research concept from diverse theoretical approaches – from the disciplines of ethics, bioethics, philosophy, anthropology, sociology and health services research. This was coupled with influences of critical theory and qualitative traditions. I began my doctoral research with a methodology that encouraged examining perceptions and meanings of the concept of ‘consent’ within a theoretical understanding that embraces the need to respect patients and patients’ family members within the Indian context. My theoretical arguments took new directions, as a result of personal, institutional and theoretical influences during various phases of my research. To illustrate how a reflexive approach and personal experiences influenced my fieldwork experiences, method and theoretical framework, and its inter-linking relationship, let me offer a brief account of the reflexive moments I encountered during the stage of data collection.

As gatekeepers, who are a part of the research process, play a significant role in determining access to participants of the research, researchers are expected to develop and sustain cordial relationships with them. Different type of gatekeepers grant different levels of access: primary gatekeepers connect the researcher to secondary level gatekeepers who then help the researcher to directly access participants for their research (Pellatt, 2003). During my research, I encountered gatekeepers at multiple levels such as the members of Ethics Committees that granted permission to access hospitals; surgeons who introduced me to the hospital staff; nursing director of the private hospital who introduced me to a group of nurses; the dean of the government hospital; practising postgraduate (PG) doctors; nurses, etc. As part of my data collection, I wanted to interview patients and their families within the hospital settings. There was no easy way to meet patients in their respective wards or rooms – each hospital had a different mechanism to access participants. The hierarchy and power dynamics within each hospital were structurally different. An important factor that determined how I gained access to the patients to carry out interviews was how I, as a researcher, inserted myself into these power dynamics, by negotiating and taking advantage of the situation. In the government hospital, the director is at the first level of gatekeeping. As soon as I got clearance from the director, I gained unhindered access to patients in three wards (General Surgery, Obstetrics and Gynaecology and Orthopaedics). The second level gatekeepers are the senior nurses on duty in particular wards. As far as I understood from my observations, senior nurses have a greater say on the question of access to the ward during most of the time, except when the doctor on duty visits the ward. Doctors visit the wards only during particular hours and do not spend much time in the ward. It is worth stating here that the visual image that corresponds with the term ‘ward’ is that of a huge rectangular room with around 20 beds in two rows, with no curtain between the beds. The letter from the director was a powerful tool for me to gain access to any place in the hospital, within the stipulated boundaries, and establish connections and thereby gain access to patients and their family members in the government hospital. During my initial interviews with patients, nurses were also present. Even though I knew (from existing literature on social power of health practitioners and from my experiences) that the presence of nurses might affect the nature of the data, I went ahead with the interviews in their presence as I was yet to decide on my strategy of data collection. My questions to the patients were apparently overheard by other patients, as well as the nurses. Soon I realized that the responses to the interview questions given by the patients and their family members were very positive and their views were similar in nature, the reason for which could be the presence of nurses. The interviews were a platform for the patients and family members to point towards each nurse they liked and state that they received good care from them. While I do not doubt the positive relationship they professed to have with the nurses, the interviews conducted in the corridors or lawns where nurses were not present were more revealing in nature. For instance, the family members of patients expressed their dissatisfaction with the service rendered. It appeared that the domineering presence of the nurses and overhearing other patients’ responses led patients to narrate their experiences in a similar manner (Hollander, 2004; Kitzinger, 1994; Lehoux et al., 2006). Upon reflection, I decided to change my method of data collection to avoid such influence. As I did not have any control over the physical structure of the ward, and the way people interacted there, I changed my approach to the patients and the method of collecting data. I requested the details of patients who had either undergone surgery in the previous week or were to undergo surgery in the coming week. After going through these details, I arbitrarily chose (using convenience sampling) the patients to meet in each ward and made sure that their neighbouring patients would not be part of any subsequent interview. Individuals quite often tend to agree with a view expressed by a large number of people. This is often underpinned by the power dynamics within the system and relationships. In my case, this power dynamics was determined by the individual patient’s relationship with the gatekeeper (the nurse) and other patients who would judge the ‘the respondent/ patient’ based on their responses (Carey and Smith, 1994; Crotty, 1998; Hollander, 2004).

While the hierarchy and power relationships were similar in nature in the private hospital, my channel to the patients/family members was different. One of the surgeons from the General Surgery department, who is also part of the Hospital Ethics Committee, introduced me to the practicing PG surgeons and asked them to facilitate my research process. In the private hospital, separate rooms were allotted to each patient and family members were allowed during visiting hours. Because of the structure of the hospital, with individual rooms for patients, patients had more privacy to share their views. The hospital had five floors, with each floor housing one or more specializations. Patients were admitted in each floor depending on the specialty care required. Each floor, octagonal in shape, had nurses’ desk at both sides. Some rooms were divided with a screen/divider, and could accommodate two patients and their caretakers. Learning from my earlier experiences at the government hospital, where the relationship between the gatekeeper and the participant adversely affected the interview process, I wanted to avoid any such influences during my interviews. I asked my liaising PG surgeon to provide the details of patients so that I could make a selection from it and meet those patients directly without involving the gatekeeper who was a PG Surgeon. When I started the process of the first interview at the private hospital, I was standing hesitantly at the door of a patient’s room. As I stood in front of the room door which had the basic details of the patient labelled on it, I found myself asking: Should I enter? Isn’t it the patient’s private space? I was not sure if I was supposed to seek permission before entering the room. I recalled a personal experience that I had as a dental patient at the hospital on my campus. I had an appointment with a dental doctor for my toothache. During my dental examination, which was in a closed room, a woman entered along with a child. From the conversations between the attending physician and the ‘intruders’, I quickly understood that the woman who had entered the room was the doctor’s colleague – a nurse from the same hospital, and the child was her son. While I was keeping my mouth wide open, the doctor turned towards the child to examine him and gave prescriptions, which took almost 10 minutes. This incident left me surprised and angry. I remember thinking whether it was my exposure to bioethics literature in general and to concepts like patient’s rights, autonomy, privacy and so on that prompted such a feeling in me. While I felt that as a patient I deserved some respect, I also acknowledge – based on my field observations at government hospital and my personal experiences in small private and government hospitals in Bangalore and Chennai – that this is how it is in this particular context and setting. When people know each other, they tend to assume an increased degree of familiarity, and it is not uncommon to extend a special treatment to an acquaintance or a friend, this is observed in healthcare system (Lewis, 2006). The problem here was that the special treatment was at the cost of treading upon the patient’s respect. The following questions lingered in my mind: do these incidents go against the concept of respect of patients? If the patient was not me, and someone who was older and a male, would the situation have been different? Moreover, since I was a student and was consulting at the campus hospital, was I seen as a marginal figure? Overall, this incident led me to reflect on how culture, power and relationships work within the hospital settings and how these may affect the way concepts like respect and patients’ privacy are understood.

With my personal experience at my institute hospital at the back of my mind, I decided against walking directly to the room to respect the patient’s privacy. I requested a junior nurse to introduce me to the patient as a researcher working with the permission of the hospital authorities, and the attending physician of the particular patient. I decided to choose a junior nurse as an intermediary because I had figured out from my experience that in private hospitals nurses are seen more as facilitators and not as figures of authority to the degree of government hospital due to structural factors and culture within private hospitals; an observation I substantiated at the stage of data analysis. I have discussed in detail the degree of micro-inequities within hospital settings which address the differences in the healthcare professionals’ behaviour towards patients and their family members (Subramani, 2018). Reflecting on my experience in front of the room door in the private hospital, I wondered why I did not think about privacy in the government hospital. This incident made me reflect whether I was being insensitive to patients of the government hospital. I also reflected on how the physical structure of hospitals influence the way we understand the concept of privacy. It seemed that the concept of privacy did not matter much at the government hospital, and the physical structure of the hospital with no curtains or walls between various beds contribute to this. At the same time, in the private hospital, patients and family are given a separate space for themselves. My experiences and my reflective thoughts on those experiences made me critically question and understand my actions and look at the larger discourses on inequity within the health system. I wondered if the higher class who had greater purchasing power could enjoy the luxury of privacy within this context. My answer is in the affirmative.

These ‘reflexive moments’ illustrate the inter-twined relationship among personal experiences, chosen methods, fieldwork sensitivity, and the moral reflection and stances of the researcher within the broader context studied. The reflexive moments and analytical questions along with the data analysis of participants’ perspectives and observations, based on critical CGT methodology, prompted me to turn towards certain philosophical literature which influenced the knowledge construction process and the moral and theoretical arguments on ‘respect for person’. The major finding of my doctoral study showed that ‘patients and family members’ are not considered as ‘knowledgeable/competent persons’ who can engage with and be a part of clinical interactions and decision making of the treatment (Subramani, 2018). They are perceived as ‘incompetents’, who cannot understand the information discussed by surgeons and nurses, due to perceived circumstantial characteristics such as illiteracy, poverty, and psychological factors such as anxiety and fear. During the analysis, I found that, surgeons and nurses used this perception to justify their paternalistic practice of not engaging with patients and family members during clinical interactions, which led to their disrespecting them. This analysis led me to pursue and promote the concept of ‘respect’’ and to focus, in particular, on the ethical argument of ‘respect for persons’, drawing from broader theoretical and ethical arguments (Beauchamp and Childress, 2001; Buss, 1999; Darwall, 1977, 2006; Dworkin, 1988; Entwistle and Watt, 2013; Macklin, 1999). The analysis further helped me to consider the relational ontology of the relationship between surgeons, patients and family members in the given context with regard to medical decision-making of elective surgery. Surgeons are required to discuss material information with them in the hospital settings in the Indian context by considering them respect-worthy as them being ‘person’ implies ‘worthiness’ and through certain moral attitude.

Significance of practising reflexivity: demystifying moral and theoretical positions

My understanding of reflexivity is strongly related to acknowledgements of qualitative research methodology as inherently reflexive (Smith, 1987, 1990). I have considered reflexivity as a critically conscious activity of meaning-making and constructing themes, ideas, concepts and arguments. A reflexive approach to research made me conscious of the decisions I made at different phases of my research: from the clothes I wore, the words I used, my hair style, body language, and so on to larger epistemological and methodological positions (Etherington, 2004; Poland and Pederson, 1998). Reflecting on the knowing process made me aware of the factors that influenced my research. The reflexive approach during the data collection stage (and data analysis), for instance, influenced the moral and theoretical concepts I eventually considered and employed during the study. I argue that by being reflexive during the research process, I was able to pay attention to the intertwining relationships of context, epistemology and methodology within research. Through reflexivity, I hold myself accountable and open for readers and peers to see how moral knowledge construction happens in the particular context. My decision to engage with the question of ‘respect for person’ and to establish it as a moral and theoretical argument in the Indian context was influenced by the epistemological, critical constructivist theoretical and methodological stances along with an inclination towards ethical universalism. Various scholars have emphasized the relevance of reflexivity in qualitative research for various reasons such as quality, rigour, validity, researcher’s capacity, being ethical, etc. (Carter and Little, 2007; Coffey and Atkinson, 1996; Denzin and Lincoln, 2011; Finlay and Gough, 2008; Hall and Callery, 2001; Mauthner and Doucet, 2003; Seale, 1999). In this article, I have offered an account of how I practised reflexivity and its influence on knowledge construction. Reflexivity prompted me to be sensitive to certain concepts, be conscious and critical of the manifestations of theoretical and moral arguments. Looking back at my experiences during the field work, especially with gatekeepers, I realize how the gatekeeper-participant relationship can influence the research process. During the process of data collection, being reflective helped me, as a researcher, to be conscious of the steps I took. By reflecting as a researcher, who has some ‘power’ (subject to gatekeeper influence) not only over the choice of approach or method for gaining access to individuals or data but also over the process of ethically reflecting upon the choices and decisions made, the researcher is made aware of her or his epistemic powers over others and how it may influence or affect knowledge construction. I believe that the reflections on the decisions made and their consequences during the research process help the researcher to employ an ethically justified research approach which holds the researcher accountable and asks for transparency. Though I made sure that I respected individual participants, sometimes it proved difficult in practice. For instance, at the government hospital, the very nature of the hospital’s architecture made it difficult to respect the privacy of individual patients and to give them control over their space. As the patients were in the common ward, I had already entered into their space by entering the wards. However, I sought their consent before interviewing them. Practising reflexivity guided me to approach the research concept of ‘informed consent’ within the context, but at the same it prompted me not to be an absolute relativist or realist, given the power asymmetry between many stakeholders in the health system. The significant aspect of practising reflexivity altered the way ‘(moral) knowledge’ is constructed. I believe that reflecting on epistemological, methodological, theoretical and moral stances made me realize the intertwining relationship of researcher experiences, knowledge and the overall research process. A reflexive approach towards qualitative research demystifies the knowledge construction process and moral positions of the study and researcher and holds the study and the researcher accountable. And I have argued that reflexivity shows the existing inter-twining relationship among personal experiences, epistemological, theoretical, moral and methodological stances and larger moral and theoretical arguments of the researcher.

Conclusion

In this article I offer an account of practising reflexivity at different stages of the research process. I have narrated certain reflexive moments from my research journey, where personal stories, researched relationships, being sensitive to context and spaces demanded reflexive analysis. I have highlighted the significance of reflexivity within qualitative study of the bioethics concept and its influence on the epistemological and methodological stance of the researcher. I have attempted to present the underlying inter-twined relationship between theoretical and epistemological assumptions which influence knowledge construction. Through an illustration of the practice of reflexivity, I have attempted to contribute to the growing recognition of qualitative research within bioethics and its significance in demystifying the moral and epistemological claims and positions of the study and the researcher. Given the recent debates on methodological discussion within empirical–ethical research in bioethics, practising reflexivity reveals the influence of researchers’ experiences and values on the research process and the moral epistemological stance which researcher endorses. I believe that in the growing field of bioethics research, the methodological discussion should not detach from epistemological analysis. One of the fundamental challenges or epistemological anxieties in ethics debates revolves around the ethical principles or values ‘taken for granted’ within the studied context (Borry et al., 2004; Davies et al., 2015; De Vries and Gordijn, 2009; Ives, 2014; Ives and Dunn, 2010; Leget et al., 2009; Molewijk et al., 2004; O’Neill, 2009; Walker, 2007 Johnstone, 2015; Salloch et al., 2015). The critical CGT methodology employed in my study considers relativist epistemological stance and acknowledges the researcher’s connectedness of experiences in theory constructions or moral arguments and helps critically examine the existing practices. Through an account of reflexivity I demonstrated the existing interlinking relationships between the researcher, the research questions, ethical research practice in the field, methodological positions and theoretical arguments, which serve to demystify the ‘objectivity’ of ‘normative’ conclusions of principles and theories of moral knowledge within qualitative bioethics debates. In this article, I have restricted the discussion to the initial phase of research process. Other phases of research, particularly data analysis, merit a much deeper analysis. While I examined the practice of reflexivity and its significance in understanding knowledge construction processes, further research on its interactive effects on moral knowledge, especially within moral epistemological debates, is called for, given the emergence of ‘empirical turn’ in bioethics research.