In a healthy policy development environment, experts may reach different conclusions about the best course of action — but at least they’ll have some credible basis for their positions, write H. K. Colebatch.
In his contribution to The Mandarin last week, Erik Baekkeskov argues that when medical experts have divergent views about the best way to respond to a potential epidemic, there should be ‘public deliberation’ on the question. Apparently, if those who know most about the problem are not of one mind on what to do about it, we should ask those who know least about it to join the discussion.
He illustrates his argument with a story about the European response to the H1N1 flu pandemic in 2000. Medical experts agreed that the best response was vaccination, and most countries had vaccination programs, but they differed in their extent. For instance, Sweden offered vaccination to everyone, but Denmark only offered it to clearly-specified categories – but in both cases, governments followed the advice of their medical experts, and the media reported this as the medically-appropriate response, and made no mention of the alternative approach next door. Barkkeskov argues that in a liberal society, the mass media would “comprehensively debate all potential policy responses”.
Well, perhaps, but those who work in government would say that it is not a debating society, but a continuing struggle to manage those aspects of our collective life which seem problematic. In this case, when the WHO had signalled the danger, government consulted with their medical experts. In nearly every case, the experts advised vaccination; in Denmark, the advice was to vaccinate those particularly at risk; in Sweden, it was to vaccinate everyone. These are not two different strategies, but variants of the one strategy, and which is chosen will reflect estimates of risk, and tolerances of risk. Is it better to vaccinate only the high-risk categories, and accept the risk of sickness and possible death among the unvaccinated, or to vaccinate everyone, and accept the risk (smaller, but still present) of sickness (and possible death) as a result of the vaccination? These would have been the issues discussed in the deliberation among the experts, and between the experts and their governments. National political styles might play a part: Sweden has a long social democratic tradition, Denmark has in recent years had more austerity and conservative government, so it is not particularly surprising that Sweden would have taken a more universalist road and Denmark a more targeted one.
So there would have been deliberation, but it was deliberation among different sort of expert: experts in the nature of the problem, experts in what could be done about it, and experts in what should be done about it – the political leaders. But in the public deliberation that Baekkeskov advocates, different sort of deliberation, in which the deliberated judgement of the local experts is contested by the judgements of other experts or of anyone who can express an opinion on the internet. This may be seen as a normatively superior way to decide the question, but the policy outcomes might be quite different. In the first place, the government would be seeking to present an assurance that the system is under control: letting the public know that an epidemic is threatening, but we know what to do about it. A debate about all potential responses signals that we don’t know what to do about it, and invites advocacy of some course of action and critique of the others, which would exacerbate the public anxiety about the epidemic.
This anxiety may be further fuelled by the sort of players who will enter the deliberation, who are likely to include those opposed (for a variety of reasons) to vaccination as such, or generally to conventional medical treatment, and will assert (without any particular evidence) that vaccination is unnecessary or even harmful. One could argue that members of the public will weigh the arguments and follow the one best supported by evidence, but it is just as likely that faced with conflicting claims, they will do nothing – in this case, not be vaccinated. This is what happened in the UK when one doctor claimed to have found a link between the MMR vaccine and autism. The scientific basis for the claim was flimsy and it was ignored by medical experts, but it was picked up by the tabloid press and social media, and vaccination rates plunged from 92% to below 80%, the number of measles cases soared, and for the first time in years, people died of measles. Some might say that this is the price of open deliberation in a liberal democratic society; policy workers might say that it is a good reason for deliberation with those who have some credible basis for their statements rather than all those who simply feel that they have something to say.
Certainly, experts may look to different sources for evidence, and may interpret it in different ways, and they cannot initiate an epidemic and allocate a third of the population to one preventive measure, a third to another, and keep a third as a control group. So experts may reach different conclusions about the best course of action – and this is what policy deliberation is all about.
Public deliberation is quite a different animal. It might be a relatively good way to seek settlement of an issue like same-sex marriage, where the issue is basically about personal values, and despite all the Angst of the campaign, the issue is now settled: it will not be revisited. But public deliberation can also be a vehicle for evidence-free emotional stampedes, as we see in the endless demands for putting more people in gaol.
In thinking about strategies for policy development, we need to be aware of the significance of context, rather than assuming that public deliberation is the best way to address a policy problem.
H.K. Colebatch established the graduate program in Social Science and Policy at UNSW, where he is now Visiting Professorial Fellow in Public Health and Policy Studies.