March-April 2012 HASTINGS CENTER REPORT 27 E xperience with public deliberation in the health field has demonstrated its potential to inform a wide range of health policy problems and ethical controversies. 1 But scholars and practitioners must turn their attention to several issues that are critical to the future of public delibera- tion practice. These include broadening the reach and scale of public deliberation, increasing its acceptability to policy- makers, and integrating it into policy decisions. Scaling Up Deliberation T he vast majority of public deliberation efforts in the health field have been undertaken at a very small scale, typically in face-to-face group settings. 2 One important ques- tion is whether these efforts can be scaled up. Deliberation is constrained by the time and commitment it takes for partici- pants to learn about issues and work through their implica- tions. Overcoming these constraints is costly, and therefore, any commitment to scaling up public deliberation must be matched by the organizational and political commitment re- quired to secure the resources needed to support it. In addi- tion, techniques for scaling deliberation to mass publics are still largely experimental. More robust roadmaps are needed to ensure that commitments to broad public deliberation are well placed and resources well spent. Advocates of scaling up argue that it increases the legiti- macy of public deliberation. They criticize small-scale delib- erative processes for their inability to represent the spectrum of views held by a given population. But legitimacy must be viewed more broadly than this. Ideally, a large-scale public deliberation would address widespread public concerns, re- flect public demands for responsive government and policy, and produce policies that the public accepts. Moreover, the ability of a public deliberation process to resonate with the democratic ideals of the population is also a key determinant of legitimacy. For example, had the recent U.S. health care reform legislation benefited from public deliberation on the relationship between its key normative feature—universal coverage—and its key structural feature—the requirement that each citizen have insurance—public perception of the law’s legitimacy might be greater than it is now. Scaling up, therefore, should be viewed as one strategy for bringing legiti- macy to the policy-making process. That said, some issues are more appropriate than others for large-scale public deliberation. Policies that stand to have a considerable impact on a large population should be delib- erated by many people over time. Any policy proposals that would markedly affect the resources of social programs would fall into this category. 3 Many such high-stakes issues are cur- rently on government agendas around the world. Helpful guidance on implementing large-scale public deliberation can be found in promising new research 4 and models such as the state-based American Health Decisions, a national coalition of citizens’ groups that uses public deliberation to involve citizens in shaping health care policy. 5 Oregon Health Decisions, a member of this coalition and an early innovator in public deliberation on health issues, used a series of community meetings in the 1980s to provide Oregon with guidance for prioritizing the medical conditions covered by Medicaid. 6 While the process did not adequately represent Medicaid recipients, it was an early demonstration that it is possible to use public deliberation to increase the legitimacy of health policy decisions. More robust models of large-scale public deliberation will likely include a variety of methods, including aggregating small-scale deliberations, us- ing technology to facilitate the participation of larger groups, randomly selecting citizen panels, collaborating with non- profit and stakeholder groups, and outreach through tradi- tional and social media. What’s in It for Policy-Makers? W hat are the conditions under which public deliberation is accepted or embraced by policy-makers, who may appear inherently reluctant to share decision-making power? 7 Canada and Taiwan offer two interesting cases. Both countries used public deliberation to inform policy discourse about na- tional health reform proposals in the early 2000s. 8 In Canada, the aim was to provide guidance to the Royal Commission on the Future of Health Care in Canada on changes to the financing and organization of health care. The Taiwanese de- The Future of Public Deliberation on Health Issues By JULIA ABELSON, MARk E. WARREN, AND PIERRE-GERLIER FOREST Julia Abelson, Mark E. Warren, and Pierre-Gerlier Forest, “The Future of Public Deliberation on Health Issues,” Hastings Center Report 42, no. 2 (2012): 27-29. DOI: 10.1002/hast.30