Social Contract, Deliberative Democracy and Public Policy
Two powerful images play a role in our political culture. The first is that of justice as a social contract by which public institutions should embody agreement on fair terms of social co-operation among citizens. The second image is that of deliberative democracy according to which public policy should be determined through processes of public reasoning by citizens or their representatives. Both assert that justifiable practices and policies are ones that, under appropriate conditions, would secure assent by members of society.
Social contract theories of justice claim that principles of justice can be defined as the outcome of agreements among persons in fair conditions of negotiation. Justice operates as a constraint on the pursuit of self-interest or the exploitation of inequalities of power. In their detailed specification the theories are complex, but the intuition behind them is a common one. Those who have witnessed an injustice will say: 'I would have resented it, had it happened to me'. Social contract theories develop this thought, asking what rational people would agree to as principles of justice if they were ignorant of their circumstances, or what reasonable people could accept when knowledgeable of their circumstances but willing to make accommodation to the interests of others.
Deliberative democracy sees democratic institutions as dependent upon processes of discussion. Political outcomes are legitimate if they are the outcome of deliberative participation by those subject to them. From the point of view of citizens, deliberative democracy has been formulated as the claim that the political process should address each citizen as someone capable of joining in a discussion and that each can be a potential agent of political decision.
To each of these two theoretical images there is a practical aspect. Ideas in the contract mode have been used to discuss the financing of long-term care, the logic of social insurance in health care, and the limits of income and wealth inequalities. Theories of deliberative democracy are associated with innovative forms of public participation in policy-making, for example deliberative polls or citizens juries, in which citizens reason together about public policy alternatives.
‘Social Contract, Deliberative Democracy and Public Policy’ is an ESRC funded research project, which runs until December 2011. Its aims are as follows:
- To explore the conceptual connections between ideas of the social contract and those of deliberative democracy, and to understand the extent to which they rest upon a common underpinning;
- To examine the institutional implications of the contract and deliberative ideas for our understanding of the political theory of a property-owning democracy and of the welfare state;
- To examine topical public policy issues in the light of the theories of social contract and deliberative democracy, and to thereby examine the role of political values in public policy-making and analysis.
The project will actively engage with the policy community, producing briefing papers which offer a normative analysis of the various policy issues. Additionally, a series of seminars and two summer schools will be held, with the aim of improving understanding amongst policy-makers of how social values are used in the policy process.
Ethics of Disasters Policy and Practice
In January this year, we held a workshop entitled The Ethics of Disasters Policy and Practice in collaboration with the UK Health Protection Agency. Participants included policy makers from government agencies and non-governmental organizations, researchers working on disaster risk reduction, clinicians experienced in disaster medicine, public health experts, and practitioners working in post-disaster reconstruction. Details about the workshop can be found here.
Discussions focused on the role of accountability, particularly at a local level, in negotiating the ethical compromises often required in disaster response, and on the -importance of collecting data to establish a sound and more easily accessible evidence base to inform disaster response efforts. Participants at the workshop are currently working together to produce a statement of the issues for publication.
Social Values and Health Priority Setting
Collaboration is ongoing with colleagues at the National Institute for Health and Clinical Excellence (NICE) and NICE International around an international research project on Social Values and Health Priority Setting. This project is seeking to explore the role of social values in healthcare decision making in a range of countries, including the UK, US, Thailand, South Korea, France, Germany and Latin America, and to produce analysis and a decision tool which will help policy makers negotiate the challenges that social values present in their decision processes.
Partners from several countries involved in this project have recently contributed to a special edition of the Journal of Health Organization and Management on Social Values and Health Priority Setting (Volume 26, no. 3). Pre-publication versions of papers in the edition can be seen on Early Cite here.
Along with colleagues from NICE, we will be leading a panel session at the forthcoming Health Technology Assessment international conference in Bilbao in June this year. More details of the project can be found on the Social Values and Health Priority Setting website.
Previous policy engagement activities in connection with this project include the following:
Discounting in health technology assessment
A paper on the issue of discounting in
cost-effectiveness assessments of health technologies was prepared for the
National Institute of Clinical Excellence in advance of a meeting of the NICE
Citizen’s Council held to consider that topic. Albert Weale delivered a
presentation to the Citizen’s Council on the basis of that paper. Information on the Citizen’s Council
discussions on discounting can be found here.
Some health interventions provide benefits over a long period of time. When appraising the cost effectiveness of such interventions, NICE uses the practice of discounting to assess their costs and benefits. Discounting is used to assess the net present value of costs and benefits that occur in the future. It can have a significant effect on the cost-benefit ratio of interventions where costs are incurred now, but the benefits stretch far into the future. Discounting benefits (because they occur in the future) can mean that the costs of the intervention appear very high in relation to the benefits.
The paper produced for NICE examined the social values issues raised by the practice of discounting in health technology assessment.
Social Values and Health Priority Setting
Two workshops have been held in collaboration with the National Institute of Clinical Excellence (NICE) on the subject of Social Values and Health Priority Setting. The first of these took place in London in February 2011, and the second in June 2011 at the Health Technology Assessment international conference in Rio de Janeiro. Delegates from the UK, USA, Columbia, Korea, Kuwait, China, Thailand, Australia, Brazil, Argentina, France, Germany and the World Bank Institute participated in the workshops. A paper examining the conceptual and normative issues around social values in health priority setting which was prepared for the first of these workshops has since been published in the Journal of Health Organisation and Management. It is available in pre-publication form on Early Cite here.
Information Governance in Health
A workshop on Information Governance in Health was held at the Nuffield Trust on 11 November 2010. A paper was produced for that workshop and has subsequently been published by the Nuffield Trust. It is available on their website and can be downloaded here.
Charities and Public Service Delivery
Albert Weale chaired a joint seminar (PDF) held by the Charity Commission and the National Council for Voluntary Organisations (NCVO) on 17 November 2010. The seminar explored the changing role of charities in public service delivery. A record of the discussions at the meeting was prepared for the Charity Commission and NCVO – the note can be downloaded here.
The following summarises the core findings of the project to date:
- Social contract theory provides a coherent and plausible interpretation of social justice and deliberative democracy when formulated in terms of the 'empirical method'. The empirical method involves looking at forms of social organisation that approximate the circumstances of justice.
- The analysis of common pool resource regimes provides us with models that can be used in such an empirical approach.
- This analysis shows us both how producers can acquire the right to the full fruits of their labour within socially agreed constraints.
- The analysis also shows the requirement of a deliberative rationality that is defeasible, this last property being closely linked to requirements of deliberative democracy.
- Redistribution is justified as a measure to even out income fluctuations across the life-cycle and in response to events that cannot be anticipated at the individual level.
- Contrary to some dominants claims in the literature on social justice, social contract theory supports a political theory of the welfare state (understood broadly as the European social model) as much, or more, than is supports a political theory of the property-owning democracy.
- In particular fields of public policy the policy paradigm supported by this approach is distinctive. For example, in priority-setting in healthcare, it supports a social insurance approach – broadly conceived – more nearly than a rights approach or a maximising cost-effectiveness approach.
- ‘New Modes of Governance, Political Accountability and Public Reason’, Government and Opposition, 46: 1 (2011), pp.58-80.
- ‘Political Theory and Practical Public Reasoning’, Political Studies, 58:2 (2010), pp. 266-81.
- ‘Clark, S. and Weale, A. (2012) 'Social values in health priority setting: a conceptual framework', Journal of Health Organization and Management, 26: 3. A pre-publication version of the paper can be downloaded here (paper attached)
- Littlejohns, P., Yeung, K., Clark, S. and Weale, A. (2012), 'A proposal for a new social values research programme and policy network', Journal of Health Organization and Management, 26:3
- Peter Littlejohns, Albert Weale, Kalipso Chalkidou, Ruth Faden, Yot
- Teerawatananon (2012) Editorial: Social Values and Health Policy: A New International Research Programme, Journal of Health Organization and Management, 26:3
- Weale, A and Clark, S (2010) ‘Co-payments in the NHS: An Analysis of the Normative Arguments’, Health Economics, Policy and Law 5:2 pp225-246 (PDF).
Seminar and Conference Presentations
- ‘The Right to Health versus Good Medical Care?’ Paper presented to conference in honour of Peter Jones, The Value and Limits of Rights, University of Newcastle, 25-26 February 2010.
- 'Social Contracts and Democratic Deliberation'. Paper presented at the conference ‘Democracy and Justice in Distribution Conflicts’, University of Frankfurt, 4-6 March 2010.
- 'Our Considered Public Judgements', Presentation at Seminar 'Modelling Futures', Centre for Research in the Arts, Social Sciences and Humanities, University of Cambridge, 28 May 2010.
- 'Our Considered Public Judgements', Presentation at Political Studies Specialist Group Conference, 'Deliberative and Participatory Democracy in the UK and Ireland', Glasgow Caledonian University, 23 June 2010.
- 'Our Considered Public Judgements', Seminar, De Montfort University, 28 April 2010.
- 'Are Social Contracts Good for You?', Department of Government Seminar, University of Essex, 15 February 2011.
- 'The Deliberative Social Contract', Lecture delivered at the Center for Ethics and Global Politics, LUISS University, Rome 14 April 2011.
- 'Social Contracts and Economic Justice', Colloquium Centre for Ethics and Global Politics, LUISS University, Rome 15 April 2011.
- 'Economic Justice and the Contract Method', Paper presented at conference on 'Contractarian Moral Theory: The 25th Anniversary of Morals by Agreement', 13-15 May 2011 York University, Toronto, Canada.
- 'Legitimacy and Political Contracting in the European Union', Conference on 'The Political Project of the European Union: Current State and Future Perspectives', Universidade Nova de Lisboa, Lisbon, 9 December 2011.
- 'Social Value for Money in Health Care', Conference 'How Can We Set Priorities in Health Care Fairly?', Nuffield Trust/University College London, 15 February 2012.
- 'Social Contract and Associative Obligation', Conference on 'Toleration and Pragmatism: Themes from the work of John Horton', Keele University, 17-18 February 2012.
- 'Public Reasoning in the Social Contract for Health', Lenten Lecture Series, Centre for Medical Law and Ethics, King's College London, 1 March 2012.
- 'Political Identity and the Social Contract', Mackenzie Lecture, Department of Politics, University of Glasgow, 5 March 2012.
- 'Social Contract and Economic Justice', Seminar, Department of Politics, University of Exeter, 7 March 2012.