Democratising health policy with deliberative mini-publics: Responsibilities, pathologies, and paradoxes

Abstract

Throughout the last couple of decades there has been an unprecedented level of global interest in democratically-deliberative methods of citizen engagement [now collectively referred to as deliberative mini-publics - hereafter, mini-publics]. Part of the allure of mini-publics is that they provide a more meaningful and effective way for governments to exchange knowledge and engage in decision-making with their citizens. Mini-publics are also known to generate transformative insights for citizens and government decision-making bodies; demonstrated in the shifting of pre-formed preferences, the creation of shared understanding, and collective decision-making. What this transformative potential might have to offer for citizens when they deliberate on health policy has not been fully explored, however, especially in Australian health policy settings where these engagement techniques are quite novel, with very little known of citizens’ experiences of deliberating and exchanging knowledge in such circumstances. For instance, it is not really known whether an exchange of knowledge even occurs, let alone, whether a just exchange occurs.

This cross-disciplinary, qualitative research reduces this gap in knowledge and demonstrates how the competing rationalities of the health policy process and the product-dominant logic within health service delivery exacerbate the challenges facing health policy administrators as they grapple with the unfamiliar nature of mini-publics. Many unintentional consequences with disabling outcomes for citizens’ experiences of exchanging knowledge and expressing their deliberative capacities ensue. Two types of epistemic injustice also became apparent: testimonial injustice, during which the citizens were not given credibility in their capacity to convey information; and hermeneutical injustice whereby the citizens were not given credibility in their capacity to understand certain things that would be in their best interests to understand.

So what do these things matter when citizens deliberate over health policy development? They matter a great deal, not least, when we consider that one of the fundamental aims of a mini-public is that the process works toward enabling citizens to gain a clearer understanding of not only what they might want, but what is also in their best interests to know. Viewed holistically, these findings demonstrate why it is important to pay attention to citizens’ experiences if mini-publics are to be institutionalised into Australian health policy settings as anything more than simply a promise of their democratically-deliberative ideal.

Paradoxically, the potential for democratic conversations to create an intersubjective space that facilitates a transformative exchange of knowledge was also evident. Although fleeting, this became apparent in such things as improved self-esteem, a greater sense of personal and community empowerment, and increased social capital and health literacy: these factors are known to contribute to people being healthier. Notably, when these findings were evident, the citizens also experienced instances of epistemic justice.

Bringing together the insights gained from the empirical findings of this research and that which has been garnered from the literature, this thesis goes on to reframe the unintentionally disabling factors found, to propose an Intentionally enabling approach to the exchange of knowledge and deliberative capacity when mini-publics are applied in health policy settings. Essentially, the propositions put forward reconsider the use of mini-publics as a more substantively equal, empowering, egalitarian, educative, and epistemically just means of health policy development.