Exploring Democratic Deliberation in Public Health: Bridging Division and Enhancing Community Engagement

Trust between citizens and the institutions that govern them is essential for effective policy, especially in public health. Across the world, higher levels of trust in government are associated with higher uptake of public health guidance, from vaccinations and use of preventive health services to physical distancing recommendations during epidemics.^1,2 However, against a backdrop of escalating political polarization and rising levels of misinformation, there has been a stark decline in public confidence in government and health institutions. In 1966, 73% of people expressed a “great deal of confidence” in those running the medical system. By 2012, only 34% did.³ In 2024, the Edelman Trust Barometer revealed that 70% of US respondents worried government leaders were purposely trying to mislead them.⁴ This trend has a negative impact on health care delivery at almost every level, from patient–doctor relationships to national population health efforts.

Public participation in decision making is one strategy policymakers can use to strengthen trust in health governance. Citizen engagement has historically been used to inform policies across a range of social issues, often to great success, yet it is still largely underused in the health sector.⁵ When efforts have been made to engage communities, they have often been through quantitative and nondeliberative frameworks favored by many health economists, such as discrete choice experiments, surveys, and polls.⁶ Meaningful public reasoning is essential to address moral and civic questions, especially in areas of scarce resources that necessitate transparent and inclusive decision-making processes.⁷

In an increasingly divided political atmosphere, there is a pressing need for policymakers to explore innovative ways to engage the public, gather diverse perspectives, and build common ground on controversial and complex issues of public health policy. Democratic deliberation offers such a framework. We argue that, by facilitating formal and goal-driven discussion between leaders and the public, deliberation can be used as a tool to build understanding between participants with competing viewpoints and can ultimately improve the quality and responsiveness of public health policy. Here we examine the potential of democratic deliberation to improve health sector governance. We discuss the unique benefits of deliberative approaches, limitations, and how deliberation can be scaled up to influence public health policy.

AN OVERVIEW OF DEMOCRATIC DELIBERATION

Democratic deliberation refers to a method of public engagement in which people from different backgrounds come together in a formal dialogue to learn about, discuss, and ultimately provide recommendations about a social problem.⁸ Although the scale and structure of these dialogues can vary, each facilitates a two-way exchange of information between organizers and participants. Core requirements of democratic deliberation include (1) recruitment of participants with diverse and representative opinions, (2) presentation of accurate and neutral evidence as background information, (3) consideration of various solutions and perspectives of other participants, and (4) pursuit of common ground to ultimately offer a recommendation.⁸

Examples of deliberation include citizen juries, citizen panels, and consensus conferences (Box 1). With these principles, democratic deliberation is distinct from other common forms of public engagement such as town halls, focus groups, and opinion polling in which there is typically a one-way solicitation of feedback without explicit efforts to discuss difficult trade-offs or arm participants with balanced evidence.⁹ Some proponents of public deliberation argue that it requires random selection of participants. In this article, we use “democratic deliberation” more broadly to encompass processes that create reasoned discussion among a representative sample of participants but do not entail strict random selection.

BOX 1—

Methods of Deliberation

Method	Stakeholder Inclusion	Transparency	Efficiency	Outcome
Democratic deliberation	Multistakeholder engagement (e.g., patients, providers, and policymakers)	Open discussions and shared rationale	Time-intensive but inclusive processes	Policies aligned with public/stakeholder needs
Online engagement platforms	Broader participation via digital platforms	Moderately transparent; real-time feedback	Flexible, asynchronous participation	Broad accessibility but potential for digital exclusion
Crowdsourcing	Involvement of large groups, including nonexperts	Limited transparency during synthesis	Fast, creative idea generation	Diverse ideas but requires moderation and synthesis
Digital town halls	Broad audience interaction through virtual platforms	High transparency; live interaction	Real time but requires significant logistics	High engagement, although outcomes can be less structured
Citizen panels	Carefully selected representative groups	High transparency; informed decisions	Time-intensive but in-depth deliberations	Recommendations that reflect informed, diverse perspectives
Asynchronous deliberation	Flexible participation by busy stakeholders	Moderately transparent; iterative input	Time-efficient for individuals	Thoughtful input but lacks dynamic interactions
Gamification/simulations	Stakeholders engage actively through interactive tools	Moderate transparency; scenario based	Engaging but resource intensive	Helps in visualizing outcomes but risks oversimplification
Social media engagement	Large-scale, diverse public input	Limited transparency; social media biases	Fast and scalable	Provides a snapshot of public opinion but lacks depth
Deliberative artificial intelligence (AI) tools	Broad input processed via AI algorithms	Low transparency; algorithm dependent	Highly efficient, scalable	Synthesizes large data sets, although nuanced human insights may be missed

The goal of deliberation has historically been to find consensus, but definitions of successful outcomes have expanded in contemporary discussions.¹⁰ Dryzek and Niemeyer argued that meta-consensus—agreement about the credibility of opposing beliefs, if not the beliefs themselves—should be considered a successful outcome. Mansbridge formulated four alternative ends to deliberation other than consensus, including expanding the borders of a problem and introducing new perspectives. Morrissey and Boswell argued that the building of common ground, wherein participants “agree on and seek to further build the shared pool of information,” should mark the success of deliberation.^11(p153) Although consensus is a worthy aim, these alternative goals of deliberation show that its benefits reside not in a specific outcome but instead within the process of deliberation itself. Examples such as the Oregon Health Plan and citizen assemblies in Canada highlight how structured dialogue can reduce polarization and illuminate shared values.¹²

We argue that democratic deliberation offers unique benefits to health policy-making that other frameworks lack, particularly with respect to inclusion of diverse, representative populations; knowledge exchange; and building of common ground. These three areas are especially useful in a climate of increasing distrust and political division that threatens the effectiveness of public health policies. Overall, democratic deliberation can improve responsiveness to and strengthen public trust in health policy decisions.

Inclusion of Diverse, Representative Populations

Traditional health policy decisions are made through feedback from a complex interplay of actors, including interest groups, lobbyists, nongovernmental organizations, and the media. This approach often overlooks the nuanced perspectives of minority groups, economically disadvantaged communities, and other underrepresented voices that typically avoid formal political discourse. Although there have been recent efforts to diversify social participation, health professionals, experts, and government cadres still dominate the process.

Democratic deliberation offers methods of systematically including unheard and previously undervalued voices. It focuses on recruiting a representative sample of participants, often through random selection that can also be stratified according to demographics.¹³ Participants in the discussion can be selected to represent groups that would otherwise be left out. For example, in a systematic review of the use of citizen juries in health policy, Street et al. found that most studies explicitly stated an aim to recruit juries that represented the community.¹² In deliberative approaches, representation can be an intentional process and allows an opportunity to weave in voices that would otherwise be neglected.

In addition, deliberations include skilled facilitators who aim to ensure that participants have an equal chance to speak, listen carefully to others, and weigh different options and trade-offs.¹⁴ Instead of hearing predominantly from the “loudest voices” who are best equipped to advocate their perspective, facilitators can help policymakers gather a holistic view of participants’ perspectives.¹⁵

Knowledge Exchange

Deliberative frameworks also act to open communication channels between the public and policymakers. Policymakers can more easily share scientific opinions and research findings with members of the public without fear of obscuration by the media or political spin.⁸ By providing background materials that showcase the range of evidence-based views and including experts who can explain complex components of an issue, deliberation can be an effective way of sharing accurate information. For example, a study on a deliberation about the allocation of ventilators in a hypothetical influenza outbreak in Maryland showed a substantial increase in participants’ understanding of the discussed issues according to surveys conducted before and after the study. After the deliberation, 80% of the study participants said that they understood issues related to deciding who received medical treatment during emergencies “very well or well,” as compared with 44% who reported an understanding of these issues before the study.¹⁶

In return, public participants can share specific and localized community values to aid in prioritization schemes. The New York City Department of Health and Mental Hygiene used deliberative strategies to gather feedback on how to allocate the distribution of COVID-19 vaccines early in the pandemic. The department found that the combination of background information and structured discussion led to more “carefully considered recommendations, allowing health departments to gain a nuanced understanding not only of what participants think but also underlying reasons why.”^{17(pp93–94)} This allowed for a “rich exploration of community values” that informed policy development.

This “give and receive” framework offered by deliberative platforms allows both policymakers and the public to benefit. The participants can obtain “stimulating and informative” background data on policy issues that affect them, and policymakers can gather detailed information on community priorities and reasons behind them.⁸ This process can facilitate information sharing and trust between decision makers and constituents and pave the way for locally resonant policy development.

Common Ground

Despite the vitriolic nature of most political discourse, common ground does exist even on the most hotly debated issues of health policy. In an Association of American Medical Colleges survey of young adults, the authors were “surprised” by areas of consensus among Democrats, Independents, and Republicans: three quarters of Republicans in the survey agreed with Democrats and Independents that access to health care is a basic human right, and more than two thirds of Republicans said that it is the responsibility of the federal government to ensure that everyone has health care coverage.¹⁸ However, these areas of agreement are often elusive in current policy discussions. Deliberative methods allow time and space for civil discussion that can reveal common ground between participants.

The formal structure of democratic deliberation encourages an environment of mutual respect among participants. By explicitly stating common rules and goals at the outset, employing trained facilitators to help navigate the discussion, and providing evidence-based background information, deliberation allows participants to wrestle with alternative opinions in a civil way. For example, more than 400 residents of Washington, DC, participated in a deliberation exercise to prioritize policies designed to address social determinants of health, such as adult education, job placement programs, housing, and public day care. In a postdeliberation survey, 92% of participants said they were treated with respect and 86% said their views were considered by the rest of the group. Moreover, although nearly 40% of participants said their individual prioritization scheme differed considerably from the group’s, more than 70% were still willing to abide by the recommendations that the group agreed on.¹⁹ Even if full consensus is not achieved, deliberation fosters an environment where common ground can be found.

Another measurable proxy for building common ground is participants’ willingness to change their mind after deliberation. Many studies on deliberative methods show that participants do change their opinions after discussion. A Canadian citizens’ dialogue exploring public opinion on public health system priorities revealed that participants’ attitudes underwent “substantial change” as a result of deliberations: the share of participants supporting increased public funding for the Canadian public health care system rose from 48% to 61%, and the percentage supporting systemic reform of the primary care system rose from 56% to 79%.²⁰ Democratic deliberation can open participants’ minds to the validity of other perspectives and help identify areas of agreement.

LIMITATIONS OF DELIBERATIVE METHODS

Although democratic deliberation is a promising and underused tool for public engagement in health policy, there are several limitations of its use. First, even with a focus on random selection, democratic deliberation cannot claim perfect representativeness. The small sample sizes of 10 to 20 people necessary for a successful discussion preclude the ability to represent all perspectives present in a population. Some have argued that this can increase bias in decision-making processes by creating too narrow of a representative body.²¹

Beyond issues of sample size, achieving a representative cross section of the population is often challenging, even when doing so is a stated aim. In the 1980s, Oregon set out to gather broad public feedback about health services included in Medicare’s basic plan. Representation was a major criticism of the effort, as 50% of the participants were health professionals, college educated, or White.²² Part of this difficulty may be participation bias. Deliberative methods require buy-in from participants and a commitment to accepting the norms of a democratic process. Recruiting participants who lack trust in governmental leadership or democratic principles can be difficult.

Deliberations also require extensive time commitments of varying length, from several hours to several days. Even when best efforts are made to reduce barriers to participation (e.g., providing additional reimbursement for child-care expenses, travel, and accommodation), nonparticipation bias still exists and can skew the composition of participants toward those with more flexible schedules.²³ Deliberation is also costly: the Organisation for Economic Co-operation and Development estimates that the cost of deliberative methods can vary widely depending on the model and the number of participants, ranging anywhere from 13 000 to 1.8 million euros.⁵ This creates challenges in scaling democratic deliberation and reinforces the importance of better understanding the types of decisions for which it can most effectively be used.²⁴

MOVING FORWARD

Given these challenges, what are the best ways to operationalize democratic deliberation to improve public health? We suggest that there are significant opportunities to use deliberative methods to improve health policy development, particularly in areas in which there are multiple ethical and evidence-based options and there is a direct impact on citizens’ everyday lives. Community engagement is especially important health policy decisions with multiple ethical options, such as how to prioritize the use of scarce health resources (e.g., organ transplants and pandemic response measures). Deliberative approaches can help decision makers adopt policies that reflect the values of the community and potentially increase the acceptance and quality of public health interventions.⁵ Evidence also shows that engaging citizens on issues that affect their daily lives (e.g., mental health service programs and reproductive health services) can strengthen their sense of political efficacy.²⁵ By reinforcing that citizens played a role in decisions that are important to them, policymakers can build trust in the democratic process.

Although there are many potential opportunities for deliberative approaches in health policy, there are still gaps in research. Critical questions requiring further research and pilots include the following:

• 1.What issues and contexts are most appropriate for deliberation? For example, deliberation is often appropriate for ethical questions but has not been used as often for technical or expert questions.
• 2.What methods of democratic deliberation are most effective at building common ground and trust in governmental processes? How can we better evaluate these endpoints?
• 3.How can deliberation be optimized for the unique challenges in public health? For example, current methodologies are difficult (although not impossible) to employ in settings where time-sensitive decision making is necessary, such as during health emergencies. Also, some health policy issues may require extensive knowledge for informed deliberation. These questions are particularly important given the resource-intensive nature of deliberation.
• 4.How can democratic deliberation be scaled or institutionalized to improve its cost-effectiveness?
• 5.To what extent should processes seek to use random selection over curation of representatives (e.g., patients and advocates)?

CONCLUSION

Amid rising political tensions, the erosion of trust in governing institutions, and worsening health outcomes, we need innovative methods of engaging the public in decision making. Although questions of public health policy are often complex and can generate divergent viewpoints, finding common ground is possible, even in the most nuanced and controversial issues.¹⁸ Democratic deliberation is an underused tool in these efforts. Moving forward, we should use its principles to foster a deeper understanding among health professionals and policymakers, build trust in institutions, and lay a foundation where everyone can find common ground.