{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T13:46:17Z","timestamp":1791985577470,"version":"4.4.0"},"reference-count":84,"publisher":"Wiley","issue":"9","license":[{"start":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T00:00:00Z","timestamp":1791936000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T00:00:00Z","timestamp":1791936000000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Bioethics"],"published-print":{"date-parts":[[2026,11]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:p>Current fashion supports aligning\u00a0health policy with the recommendations of deliberative forums, or mini\u2010publics. These forums'\u00a0participants 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\u00a0vote on and sometimes rank policy recommendations. According to supporters,\u00a0a deliberative democratic\u00a0process 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\u2010partite feature of nearly all instances of democratic deliberation on regional, national, and global health policy under current best practice, which I call the \u201cScaleup costs, Size, and Statistics\u201d (\u201c3S\u201d) challenge, largely blocks these alleged welcome tendencies. In particular, barring radical changes, true democratic deliberation is expensive to scale, keeping feasible mini\u2010publics small and irregular. That makes concluding from mini\u2010public recommendations about\u00a0the population's hypothetical consent, values, and will statistically unreliable. It also caps low mini\u2010publics' 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 \u201clistened to,\u201d whether or not it is. But those merits are modest, contingent, and most accentuated under\u00a0different 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.<\/jats:p>","DOI":"10.1111\/bioe.70191","type":"journal-article","created":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T12:57:07Z","timestamp":1791982627000},"page":"1025-1038","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["The Scaleup Costs, Size, and Statistics Challenge to Democratic Deliberation on Health Policy"],"prefix":"10.1111","volume":"40","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1056-6609","authenticated-orcid":false,"given":"Nir","family":"Eyal","sequence":"first","affiliation":[{"name":"Global Business School for Health University College London London UK"},{"name":"Rutgers School of Public Health, Institute for Health, and Philosophy New Brunswick New Jersey USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,10,14]]},"reference":[{"key":"e_1_2_9_2_1","volume-title":"Politics Without Politicians: The Case for Citizen Rule","author":"Landemore H.","year":"2026"},{"key":"e_1_2_9_3_1","doi-asserted-by":"crossref","DOI":"10.1093\/oso\/9780198856368.001.0001","volume-title":"Lottocracy: Democracy Without Elections","author":"Guerrero A.","year":"2024"},{"key":"e_1_2_9_4_1","doi-asserted-by":"crossref","DOI":"10.1093\/9780191982903.001.0001","volume-title":"The Lottocratic Mentality: Defending Democracy against Lottocracy","author":"Lafont C.","year":"2024"},{"key":"e_1_2_9_5_1","doi-asserted-by":"crossref","DOI":"10.7551\/mitpress\/2324.001.0001","volume-title":"Deliberative Democracy: Essays on Reason and Politics","author":"Bohman J.","year":"1997"},{"issue":"1","key":"e_1_2_9_6_1","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1017\/S0003055419000674","article-title":"A Formal Theory of Democratic Deliberation","volume":"114","author":"Chung H.","year":"2020","journal-title":"American Political Science Review"},{"key":"e_1_2_9_7_1","volume-title":"Democracy and Deliberation","author":"Fishkin J. 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