Title:
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Is there a moral requirement to involve the public in strategic health care planning and organisation?
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I have analysed whether or not there is a moral obligation to involve the public
in the planning and organisation of health services. I have concluded that
there is a moral obligation to involve the public, but that this obligation is parti-resultant
and only extends to morally constructed, deliberative processes that
can meet democratic conditions for political equality, effective participation
and enlightened understanding. I suggest that the public democratic right to
directly influence the nature and design of health services is justified by the
direct impact that health provision has on each individual's wellbeing and
welfare.
Health care provision is aimed at restoring and maintaining the health of the
population. However, In order to meet population health needs it is necessary
to understand what health is. I contend that the meaning of health is highly
contested and subjective, therefore, in understanding what health is it is
necessary to seek different perspectives from a broad cross section of the
public.
I suggest that current models of decision-making in health are not sufficiently
well informed by the wider public perspective of health. Deliberative models of
decision-making that involve the public as equal partners have the potential to
bridge this deficit. However, involving the public in decision-making does not
mean that the public could, or should, necessarily have their preferences met.
Autonomous choice can be embraced within a deliberative decision-making
model in this context but only if the conception of autonomy is relational
autonomy. That is; choice can only be morally supported when made in
relation to obligations and responsibilities owed to others.
Public involvement, through deliberative fora, has the potential to engage
individuals who have previously been marginalised or excluded from decision making
in health and has the potential to transform services in the light of new perspectives. However, this will only be realised if there is a will to transform
ways of working to enable different voices to compete with existing power
structures and orthodoxies. However, if final decision-making continues to
reside with politicians and bureaucrats, merely informed by the public through
deliberative fora, the risk is that traditional decision-makers will continue to
ignore the deliberations of the public and fail to transform services to better
meet different public needs. Alternatively, if public decisions are to carry
weight and promote change the public must accept the responsibility and
accountability for that influence, and as yet there is no system for this level of
accountability to occur.
I conclude that although public involvement is morally justifiable, for the public
to make any reliable impact there must be significant investment in creating a
climate that supports and promotes effective involvement and this may be too
prohibitive to engage with, except in limited and exceptional circumstances;
leaving a representative model of decision-making with in-put from the public
as the compromise, default position.
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