The Scaleup Costs, Size, and Statistics Challenge to Democratic Deliberation on Health Policy

Current fashion supports aligning health policy with the recommendations of deliberative forums, or mini-publics. These forums' participants are selected randomly from the general public (sometimes with overrepresentation of direct stakeholders or of underrepresented sectors). After being informed and exchanging public reasons with fellow participants under discursive rules that engage all as equals, participants vote on and sometimes rank policy recommendations. According to supporters, a deliberative democratic process that holds such forums and translates their recommendations to policy legitimizes resulting policy. That's thanks to this process's tendencies to strengthen democratic consent, to uncover which policy option is objectively best, to align policy with lay normative outlooks, and to educate the public. I argue that one tri-partite feature of nearly all instances of democratic deliberation on regional, national, and global health policy under current best practice, which I call the "Scaleup costs, Size, and Statistics" ("3S") challenge, largely blocks these alleged welcome tendencies. In particular, barring radical changes, true democratic deliberation is expensive to scale, keeping feasible mini-publics small and irregular. That makes concluding from mini-public recommendations about the population's hypothetical consent, values, and will statistically unreliable. It also caps low mini-publics' contribution to public education. In these ways and in others, the long list of alleged welcome tendencies of proper democratic deliberation on health policy, and the related contribution to political legitimacy, is largely a fiction. Public deliberation does have modest true merit, for example, providing relevant qualitative input about the lay public's occasional factual insights and many endemic errors; and making the public feel "listened to," whether or not it is. But those merits are modest, contingent, and most accentuated under different institutions than envisaged in deliberative democratic literature. Certainly there is room for democratic deliberation, potentially of new breeds, but only as part of the mosaic of health policy design, alongside familiar methods like general elections, public surveys, representative government, and expert decisionmaking. The main question is which method to use when.