In this article we describe the process of developing an ethics support service in a Dutch academic hospital by means of implementing moral case deliberation (MCD). In MCD, health care professionals discuss their moral issues pertaining to a real case in order to come to mutual understanding and/or a shared idea of what is best to do and in which way. MCD is inspired by the philosophy of dialogical and hermeneutic ethics. Equal dialogue and critical constructive reflection are both important aims and means of MCD. This requires equality of perspectives, time to deliberate about values and considerations, and active involvement of all participants (ownership). However, within the context of an academic hospital, these conditions are not evident, given the prevalence of power and hierarchy, the need for efficiency and time management, and the emphasis on experts' advice instead of joint responsibility. This paper introduces the core features of the philosophical background of MCD and describes ways of dealing with some tensions between MCD's philosophical inspirations and the practical context of an academic hospital while implementing MCD. The paper shows that these philosophical inspirations can be helpful in the cooperation with an academic hospital when implementing MCD together. This joint process of making MCD meaningful and useful for the practice while dealing with different tensions, is as important as offering high quality MCD sessions.