What is good public deliberation?

March-April 2012 When assigned the task of describing and updating essential health benefits for qualified health plans in the Affordable Care Act, the Secretary of Health and Human Services turned to the Institute of Medicine for advice. An IOM committee recommended that “structured public deliberative processes be established to identify the values and priorities of those citizens eligible to purchase insurance through the exchanges, as well as members of the general public.” The IOM argued that “the inevitability of limitsetting requires a nonpartisan, transparent process for eliciting the core values of key players, including taxpayers and health plan enrollees. Health care has always been steeped in tradeoffs . . . Incorporating an informed citizen perspective can make these tradeoffs more responsible, responsive, and acceptable to the public.” Even this brief excerpt mentions numerous ways—transparency, informativeness, acceptability—by which the success of public deliberations might be judged. Theories of deliberative democracy do not prescribe a single method of doing deliberation, and uncertainty and debate remain about the best approach. Theories do, however, provide guidance for empirical research about the quality of deliberation, evidence that is vitally needed to ensure that deliberative procedures do not produce more harm than good. Deliberation tends to change things—opinions, rationales, intensity, attitudes toward opposing views, and so on—and often aims to influence policy. If deliberation brings about these changes primarily via social power, say, or group conformity, then it could magnify social inequality and pervert its own goals. The quality of public deliberation depends on more than how and whether it changes anything: Many theorists hold that high-quality deliberation is intrinsically valuable as a direct indicator of justice. Putting these theories to the test can yield evidence about the quality of deliberative procedures and whether they bring about the presumed benefits. Such evidence can enable improvements based on lessons learned. Some universally relevant criteria can be used to judge deliberative events. We divide these into three domains: structure, processes, and outcomes.