The fifth measure to consider is common good. While it is important to measure the level of justification participants provide for their arguments in relation to deliberative quality, it is also interesting to know the content of those justifications. For example what subjects / reasons are participants using to justify their argument? For this study, common good and stories have been included in the analysis as examples of content used to justify positions.
In early versions of deliberative democracy, common good was essential to the process because it ensured that self-interest was excluded and that decision making was based on the common good or public interest. Common good encourages participants of deliberation to take a more broad view of important decisions. In healthcare and for NICE perhaps, this is exceptionally important because public health essentially spans across many different
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populations. Given that NICE are interested in social value judgements as well as scientific assessments, there might be a high frequency of reference to the common good as this is underpinned by social value judgements. Common good is also a core characteristic of type I / micro deliberation. This is because in micro conceptions of deliberative democracy
participants should be “committed to reaching a mutual understanding in view of the collective good” (Hendriks, 2006, 492).
Table 5.7 displays frequency data for the NICE vitamin D and NSP samples. This has also been compared with citizens in the Belgium sample and parliamentary data in a public setting. The parliamentary data has been used to explore if setting influences the content of
justification i.e. does deliberating in public encourage a higher frequency of reference to the common good. NICE do allow the public to attend PHAC meetings however there were very few observers at the meetings observed in this research. The citizen data has been used to explore if committee members refer more to the common good when compared with citizens.
Coding was applied to speech acts where; a) the speaker referred to benefits and costs for all groups represented in the deliberation; and when b) the speaker did not refer to benefits and costs for all groups represented. Examples of the common good in the NICE samples
included reference to whole population approaches, free, universal, low costs supplements for all groups, and universal policies.
Table 5.7: NICE, citizens, parliamentarian public data - Common good data (percentage and number) NICE (Vitamin D) NICE (NSP) Citizens (Belgium) Parliamentarians (UK, Public) Refers to all groups 13.7% 19.1% 7.0% 30.5%
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In table 5.7, there was a higher frequency of speech acts referring to the common good in the NSP sample (19.1%) when compared with the vitamin D sample (13.7%). This difference perhaps may be due to the topic under deliberation. Committee members in the NSP sample felt that it was more relevant to justify their position by referring to the common good in this topic.
The highest frequency of reference to the common good was by parliamentarians in public settings (30.5%). In the NICE PHAC meetings, there was slightly more observers in attendance at the NSP PHAC meetings when compared with the vitamin D meetings and the more public nature could explain why there was a higher frequency of referring to the common good when compared to the vitamin D sample.
The data shows that when compared with the other cases, citizens rarely refer to the common good when providing justifications for their arguments. This may be because the topic under deliberation was contested and therefore participants were voicing their own concerns rather than the common-good. They may have been more self-interested.
When compared with citizens, NICE committee members appear more likely to justify their arguments using the common good. Again, this may well be dependent on the context and the topic of deliberation. Public health guidance makes recommendations for populations and individuals on activities, policies and strategies that can help prevent disease and improve health. Given that public health focuses on large populations and on prevention and
improvement of populations, it is maybe not surprising that committee members involved in developing public health guidance make more reference to the common good than other types of deliberators i.e. citizens.
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In the interviews, some committee members discussed the type of expertise and information they brought to meetings. Two committee members interviewed were members of both the vitamin D and NSP PHAC meetings. One was a community member and the other was a core member. Both said that their role was to provide a generalist, humanistic perspective
evidencing that some members do think about the wider impact that the guidance will have i.e. the common good.
"I bring this humanity, you know, to the guidance in a way where some of the
professionals can get wrapped up in all the compounds and chemicals" (Community Member NSP, VD)
"The expertise that I said that I would bring to it was expertise in health related behaviour change...Quite a lot of expertise in taking the patient perspective and communication with patients and the general public" (Core Member NSP and VD)
The DQI and interview data support that on occasion committee members were able to move beyond self-interest while developing public health guidance when compared with other deliberators such as citizens. This has been supported in other NICE research where members were described as being able to provide a “generalist perspective” and “ability to relate things to the real world” (Ursu et al, 2010, 21).
Overall however, there was a higher frequency of no reference being made to the common good in the NICE samples which is surprising given that NICE are concerned with social value judgements. The frequency of reference to the common good was expected to be higher given this emphasis. The deliberation appears very much in line with expert deliberation which “typically does not address moral norms or the common good in any direct way” (Moore, 2016, 196). This is further echoed by committee members who expressed that NICE based their decisions on technical judgements such as facts and statistics rather than on moral norms. The comments below are provided by committee members involved in the NSP
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process who clearly felt that the process of developing guidance was primarily led by evidence.
"...I think the fact that they make decisions based on evidence is absolutely excellent and that's what they're looking for. So whether it’s external people they bring in or whether it's the committee themselves, it always comes back to that question of have we got the evidence to make that recommendation?" (Field Worker, NSP)
"It wasn't just a group of people sitting down and writing a document, it really was evidence led" (Topic Expert, NSP)
"I think what is considered scientifically strong evidence is what NICE is briefed to consider. This is given the greatest weight” (Core Member, NSP/VD)
It is clear that the drive for information to be evidence led is an organisational priority. Previous research found that NICE community members felt that the evidence presented at committees was very clinical and this was viewed by committee members as being
problematic because the focus of committees is on the development of public health guidance and not clinical guidance (Ursu et al, 2010, 13). The development of public health guidance needs to be different from other types of guidance such as clinical guidance and requires the involvement of a variety of evidence and not just statistics and facts. When public health guidance was added to NICE’s remit, this was something that was understood by the
organisation. Kelly recognised that evidence from other methods and designs would have to be appraised and that the data and evidence drawn upon in public health work would need to be broad and go beyond medical science to include the social sciences (Kelly et al, 2010). This created two immediate problems “a broader more epistemologically and
methodologically diverse evidence base; and, multiple levels of analysis and operation” (Kelly et al, 2010, 1059) for NICE committees to include and consider. Taking this into account, it is no easy task to develop public health guidance as a multitude of evidence and information needs to be considered. Finding a balance of what type of evidence to include is challenging for NICE. There are examples of moral, ethical and social evidence which could
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be included in PHAC meetings. These forms of evidence are typically qualitative and not based on clinical epidemiology (Upshur, VanDenKerhof and Goel, 2001). An inclusive model of evidence should be utilised by NICE which incorporates clinical and technical evidence but also social, moral and ethical. This inclusive approach may be better achieved in practice if NICE accessed a range of deliberative spaces, perhaps in the macro sphere, and included a broader type of committee member in their PHAC meetings such as social scientists and patients and not just topic experts or epidemiologists.
It is important to note however that one committee member involved in both processes felt that NICE was changing and had made improvements to be less driven by data suggesting that they were open to including other forms of information.
"I think you can get a bombardment of research and figures and stuff like that without actually maybe looking a little bit more at OK so what do we have out there at the moment? What's happening...it's very much based on facts, figures, research and the like...But they've really improved since that" (Core Member, NSP and VD)
The parliamentary data tells us that the common good is used more often in public arenas. Again, this is not surprising. Actors in public “appear to have a stronger pressure to make appeals to the common good” (Steiner et al, 2004, 30) and justify their positions with
references that will appeal to the common good. Parliamentarians also want to get re-elected so are more likely to make appeals to the common good. As previously stated, NICE do allow the public to attend their PHAC meeting. There were members of the public in attendance but they were not always visible to the committee and there wasn’t large representation. This may explain the lack of common-good in the NICE deliberation as committee members did not have to appeal to the public.
The publicity principle which was discussed in chapter two is interesting to re-visit given this finding. Gutmann et al (2004) argue that deliberation occurring within a deliberative
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democratic process must be public. Habermas (2006) insists that publicity and transparency encourages good deliberation and legitimacy, however some see limits to the publicity
principle. Publicity could change the dynamics of deliberation causing deliberators to provide reasons which they do not fundamentally believe or support. For example, public deliberation may influence participants to say what they think the public wants to hear in order for them to gain more support or approval (Chambers, 2006). This is not terribly democratic but may suggest why there is a higher frequency of reference to the common good in public settings. If more or less members of the public attended NICE meetings, this might possibly change the frequency of reference to the common good and is something which NICE might consider.