Intelligently Designing Deliberative Health Care Forums: Dewey’s Metaphysics, Cognitive Science and a Brazilian Example

1. Intelligently Designing Deliberative Health Care Forums:Dewey’s Metaphysics, Cognitive Science and a Brazilian Example Shane Ralston, Ph.D. University of Maine (Orono) Penn State University (World Campus)

2. Preliminaries: What is Health Care Priority-setting? • Imagine you are the CEO of a hospital [ . . . ]. Decisions are constantly being made in your organization about how to spend the organization’s money. The amount of money available to spend is never adequate to pay for everything you wish you could spend it on, therefore you must set spending priorities. There are two questions you need to be able to answer . . . How should we set priorities in this organization? How do we know when we are doing it well? -Doug Martin and Peter Singer (2003:60)

3. Health Care Priority-setting—Consultative or Deliberative? • Consultation, or the ‘technocratic approach’ • One-way: survey raw opinion, measure public values • 3 Limitations • Deliberation, or the ‘participatory approach’ • Two-way: education, inquiry, discourse • Better than consultation—why? Focus on process and product, justification and outcome

4. Objections to the Deliberative Approach and my Thesis • Objections to deliberative policy-making: (i) ignores feasibility constraints, (ii) masks power differentials, (iii) breeds groupthink, etc. • Most devastating objection in the policy context: limited cognitive resources (Richard Posner) • My central claim: By designing deliberative forums to imitate the natural pattern of human experience it is possible to overcome the ‘limited cognitive resources’ objection

5. Two phases of experience: (i) primary and (ii) secondary Once learned through focused inquiry (i.e., as knowings in secondary experience), experiential lessons are stored or funded as meaningful data and tools (i.e., as settled objects or knowns in primary experience) for use in future inquiries Sea tides metaphor: experience is a cyclical, ebb-and-flow movement between . . . cognitive knowings/inquiry (secondary experience) pre/non-cognitive (or felt) havings regulated by the products of previous inquiries (primary experience) John Dewey’s Metaphysics of Experience

6. Cognitive Science Research on Schemas and Frames • Schemas: organized structures of information that guide our day-to-day behavior, perception and memories • Cognitive misers • Frames: linguistically cued ideas or concepts that fit within a broader set of values or a distinct worldview • George Lakoff • Dewey’s equivalent: Habit • So, cognitive science research supports metaphysics of experience • Normative conclusion: the design of deliberative health care policy-making forums should imitate the natural ebb and flow pattern of experience

7. Case Study: São Paulo’s Municipal Health Council • In 1988, Brazilian Constitution mandates deliberative institutions operate in parallel with municipal governments • Advantages • Inclusive of participants with diverse perspectives/values • Pools cognitive resources • Emulates ebb and flow pattern of experience

8. Conclusion: Experience and Deliberative Policy-making from a Deweyan Perspective • The ebb-and-flow movement of discourse presupposes the similar movement of experience • Dewey: “a universe of experience is a precondition of a universe of discourse” (LW 12:74) • No intention of foreclosing opportunities for future reconsideration