Creating pathways to just and sustainable food systems with citizen assemblies.

Food systems affect and are affected by the interrelated crises of climate change, biodiversity loss, resource depletion and health, amongst others. Transforming to sustainable approaches is vital, yet entangled with uncertainties, complexity and a great value diversion with stakeholders. Deliberative processes such as citizen assemblies offer a valuable contribution to such a transformation, since the crises and their responses affect everyday life, and therefore inviting individual and collective action. Still, who is included and whose knowledge counts affects outcomes. Theoretically anchored in concepts of environmental justice, our study analyses three nation-wide citizens' assemblies on climate change and food systems from Western Europe. It assesses (a) how citizens' assemblies can incorporate a broad set of viewpoints and design more substantive political answers to current crises, and (b) whether citizens' assemblies include environmental justice aspects to facilitate social change. The paper argues that systematic and methodologically reflected inclusion of various positionalities can inspire decision-making processes in that they incorporate procedural, recognition, and distributional justice to address problems of climate change or modern food systems. It concludes with offering further approaches to include more than scientific knowledge in deliberative processes for a just transformation towards sustainability.

Public deliberation on health gain measures.

Researchers and decision-makers use health gain measures to assess the value of health interventions. However, our current understanding of how these measures are understandable and accessible to the community is limited. This study examined a diverse group of stakeholders' attitudes and preferences for 9 commonly used health gain measures. We recruited 20 stakeholders, including patients, caregivers, pharmacists, allied health professionals, and citizens. We conducted 2 in-person deliberative meetings in which participants learned, discussed, deliberated on, and ranked 9 health gain measures. The final ranking conducted after unified deliberation showed the quality-adjusted life year (QALY) as the top-ranked measure, followed by the clinical benefit rating method used by the U.S. Preventive Services Task Force, and multicriteria decision analysis (MCDA). We identified 3 themes during deliberations: the importance of using patient values in population-based health gain measures, examining complementary measures together, and choosing measures that are intuitive and easy to understand. Future policymaking should consider incorporating the QALY, clinical benefit rating, and MCDA into prioritization decisions.

The Life Attachment Scale (LAS-R).

INTRODUCTION: The proposed concept of secure/insecure lifeattachment reflects the experience of the world and life as a good (or insecure/threatening) place to be. The present article describes the theoretical foundation, development, and validation of a revised measure that captures the phenomenon of secure/insecure life attachment. The revised scale consists of seven dimensions: (1) Coexistence, (2) Reliability, (3) Safetiness, (4) Integration, (5) Inclusion, (6) Participation, and (7) Deliberation. METHODS: In three studies (N = 1,059), we examined the factor structure and the convergent and predictive validity of the Life Attachment Scale-Revised (LAS-R). RESULTS: Our results support a seven-factor structure of the scale, reflecting the aforementioned dimensions. Furthermore, convergent and predictive validity were established through correlations with related concepts of life satisfaction, flourishing, openness to the future, and perceived stress. CONCLUSION: We have devised and substantiated a scale adept at gauging dimensions of secure and insecure/disordered life attachment. Empirical evidence from statistical analyses supports the assumption that the LAS-R is psychometrically sound, establishing its reliability and validity as a dependable instrument. Thus, the scale has promising implications for developing the empirical base for research in many areas of psychology, sociology, and the social sciences.

Workshop on hastened death as "space for an appreciative discussion": A qualitative study.

AIM: To evaluate the suitability of a drama-based workshop as a method for ethical deliberation. BACKGROUND: Nurses worldwide are inadequately prepared to care for people who desire hastened death, which can lead to ethical and moral dilemmas. To address this problem, we developed a drama-based ethical deliberation workshop to assist nurses in these situations. Senghor and Racine's three moments of ethical deliberation and their quality criteria served as basis for evaluation. DESIGN: Qualitative descriptive study design. METHODS: Non-participant observations and a survey with incomplete sentences to be completed by nursing students were used. Data analysis followed Mayring's deductive content analysis approach. RESULTS: All three moments of ethical deliberation according to Senghor and Racine were identified. Participants recognised hastened death as morally problematic, shared their experiences and gained a deeper understanding of the problem. They reported feeling better prepared for encounters with persons seeking assisted suicide. In terms of its quality, the drama-based workshop achieved good and partial ethical deliberation. CONCLUSIONS: The workshop has demonstrated its suitability as a method for ethical deliberation. The workshop should be complemented by specific modules, such as communication skills and be tailored to other professional groups. A validated instrument is needed to ensure a more comprehensive assessment of the quality.

Time pressure and deliberation affect moral punishment.

The deliberate-morality account implies that moral punishment should be decreased with time pressure and increased with deliberation while the intuitive-morality account predicts the opposite. In three experiments, moral punishment was examined in a simultaneous one-shot Prisoner's Dilemma game with a costly punishment option. The players cooperated or defected and then decided whether or not to punish their partners. In Experiment 1, the punishment decisions were made without or with time pressure. In Experiment 2, the punishment decisions were immediate or delayed by pauses in which participants deliberated their decisions. In Experiment 3, participants were asked to deliberate self-interest or fairness before deciding whether to punish their partners. Different types of punishment were distinguished using the cooperation-and-punishment model. In Experiment 1, time pressure decreased moral punishment. In Experiment 2, deliberation increased moral punishment. So far, the evidence supports the deliberate-morality account. Experiment 3 demonstrates that the effect of deliberation depends on what is deliberated. When participants deliberated self-interest rather than fairness, moral punishment was decreased. The results suggest that unguided deliberation increases moral punishment, but the effects of deliberation are modulated by the type of deliberation that takes place. These results strengthen a process-based account of punishment which offers a more nuanced understanding of the context-specific effect of deliberation on moral punishment than the deliberate-morality account.

Improving memory through choice and deliberation in decision-making: Evidence from ERPs.

The goal of decision-making is to select one option and disregard the others. However, deliberation can also create a memory association between the chosen and unchosen options. This study aims to investigate how choice and deliberation affect the memory of postdecision options and the underlying mechanisms. Using event-related potentials (ERPs), we examined item recognition (Experiment 1) and associative recognition (Experiment 2) following certain and uncertain decisions. In Experiment 1, items that were chosen in certain decisions were remembered better than unchosen items. There was no difference between chosen and unchosen items in uncertain decisions. Moreover, a late recollection-related LPC (a late positive component) old/new effect was larger for chosen items than unchosen items in certain decisions. The early familiarity-related FN400 and the late recollection-related LPC old/new effects were significant for chosen and unchosen items in uncertain decisions. In Experiment 2, there was no difference in performance on associative memory. A FN400 old/new effect (an index of integration) in certain or uncertain decisions was not observed. Although significant LPC old/new effects were found in both certain and uncertain decisions, no difference was found between them. These results propose that decision-making can enhance item memory performance through two distinct processes: value and elaboration. Elaboration involves focusing on the details within items rather than integrating items into a cohesive whole.

Ecologising Invited and Uninvited Patient Participation in Russia.

INTRODUCTION: Public participation can be both supported and limited by decision-makers. Therefore, citizens either participate in top-down approved formats or have to turn towards subversion. These different participation practices, called invited and uninvited, are often treated by researchers as mutually exclusive. In this article, we present the case of patient organisations' involvement in various state-controlled deliberation bodies in Russia, which does not fit into a smooth binary distinction of the patient participation practice. Instead, identified patient participation practices combine interaction approved by gatekeepers with interaction, which are subversive and grassroots-initiated. Conceptually, it means that invited and uninvited participation can be better understood as intertwined ecologies. METHODS: The article is based on a qualitative ethnographic study, which includes participatory observations of the meetings of state-controlled public participation bodies, such as public councils, 51 semi-structured interviews with members of these bodies and an analysis of the relevant policy and methodological documents. Informed consent to record and transcribe all interviews was obtained. Thematic analysis has been used to produce the results. RESULTS: Russian patient organisations often work informally and independently of state-approved practices expected from them. Some subversive practices happen outside official meetings, others become widely used best practices and others remain everyday mundane interactions, which contribute to the maintenance of the independence of patient organisations against otherwise dominating and nondemocratic state actors. CONCLUSION: The ecologising approach to patient participation, which interprets invited and uninvited practices as interconnected, has better explanatory power for cases in which citizens maintain independence despite all limitations associated with authoritarian settings. Conceptualising invited and uninvited practices as situations, or separate time- and space-bound events, is a helpful theoretical framework for understanding diverse and seemingly contradictory public participation practices. PATIENT OR PUBLIC CONTRIBUTION: Research participants communicated amendments to the initial research framework to incorporate their needs. Repeated interviews allowed triangulation of preliminary findings with research participants. The article is co-authored with the patient organisation representative, who has contributed directly to data analysis and presentation.

Effect of Private Deliberation: Deception of Large Language Models in Game Play.

Integrating large language model (LLM) agents within game theory demonstrates their ability to replicate human-like behaviors through strategic decision making. In this paper, we introduce an augmented LLM agent, called the private agent, which engages in private deliberation and employs deception in repeated games. Utilizing the partially observable stochastic game (POSG) framework and incorporating in-context learning (ICL) and chain-of-thought (CoT) prompting, we investigated the private agent's proficiency in both competitive and cooperative scenarios. Our empirical analysis demonstrated that the private agent consistently achieved higher long-term payoffs than its baseline counterpart and performed similarly or better in various game settings. However, we also found inherent deficiencies of LLMs in certain algorithmic capabilities crucial for high-quality decision making in games. These findings highlight the potential for enhancing LLM agents' performance in multi-player games using information-theoretic approaches of deception and communication with complex environments.

Time pressure increases children's aversion to advantageous inequity.

The relative contribution of intuitive and reflective cognitive systems in cooperative decision making is a topic of hot debate. Research with adults suggests that intuition often favors cooperation, but these effects are contextually sensitive. Emerging evidence has shown that in many contexts children show a tendency toward intuitive cooperation, but research investigating these processes in children is sparse and has produced mixed findings. In the current study we investigated the influence of intuitive and reflective decision processes on children's fairness behavior by manipulating decision time. We tested (N = 158) pairs of children between 4 and 10 years of age from a rural community in Canada. Children's decisions to accept or reject allocations of candies were either made under time pressure or after a 10-s delay. We assessed the impact of decision time on children's aversion to inequitable distributions of resources by comparing their responses to equal allocations with either disadvantageous allocations or advantageous allocations. We found that children showed a greater age-related increase in advantageous inequity aversion when decisions were made under time pressure compared to when they were made after a delay. In contrast, we did not observe a significant impact of decision time on the development of disadvantageous inequity aversion. These findings suggest that intuitive decision processes may contribute to the development of fairness concerns in middle childhood.

Ethics support for ethics support: the development of the Confidentiality Compass for dealing with moral challenges concerning (breaching) confidentiality in moral case deliberation.

BACKGROUND: Confidentiality is one of the central preconditions for clinical ethics support (CES). CES cases which generate moral questions for CES staff concerning (breaching) confidentiality of what has been discussed during CES can cause moral challenges. Currently, there seems to be no clear policy or guidance regarding how CES staff can or should deal with these moral challenges related to (not) breaching confidentiality within CES. Moral case deliberation is a specific kind of CES. METHOD: Based on experiences and research into MCD facilitators' needs for ethics support in this regard, we jointly developed an ethics support tool for MCD facilitators: the Confidentiality Compass. This paper describes the iterative developmental process, including our theoretical viewpoints and reflections on characteristics of CES tools in general. RESULTS: The content and goals of the ethics support tool, which contains four elements, is described. Part A is about providing information on the concept of confidentiality in MCD, part B is a moral compass with reflective questions, part C focuses on courses of action for careful handling of moral challenges related to confidentiality. Part D contains general lessons, best practices and tips for dealing with confidentiality in future cases. CONCLUSIONS: This paper concludes with providing some lessons-learned related to developing ethics support tools and some reflections on issues of quality and normativity of ethics support tools.

Public Reason, Bioethics, and Public Policy: A Seductive Delusion or Ambitious Aspiration?

Can Rawlsian public reason sufficiently justify public policies that regulate or restrain controversial medical and technological interventions in bioethics (and the broader social world), such as abortion, physician aid-in-dying, CRISPER-cas9 gene editing of embryos, surrogate mothers, pre-implantation genetic diagnosis of eight-cell embryos, and so on? The first part of this essay briefly explicates the central concepts that define Rawlsian political liberalism. The latter half of this essay then demonstrates how a commitment to Rawlsian public reason can ameliorate (not completely resolve) many of the policy disagreements related to bioethically controversial medical interventions today. The goal of public reason is to reduce the size of the disagreement by eliminating features of the disagreement that violate the norms of public reason. The norms of public reason are those norms that are politically necessary to preserve the liberal, pluralistic, democratic character of this society. What remains is reasonable disagreement to be addressed through normal democratic deliberative processes. Specific issues addressed from a public reason perspective include personal responsibility for excessive health costs, the utility of a metaphysical definition of death for organ transplantation, and the moral status of excess embryos generated through IVF and/or their use in medical research.

What are the views of Quebec and Ontario citizens on the tiebreaker criteria for prioritizing access to adult critical care in the extreme context of a COVID-19 pandemic?

BACKGROUND: The prioritization protocols for accessing adult critical care in the extreme pandemic context contain tiebreaker criteria to facilitate decision-making in the allocation of resources between patients with a similar survival prognosis. Besides being controversial, little is known about the public acceptability of these tiebreakers. In order to better understand the public opinion, Quebec and Ontario's protocols were presented to the public in a democratic deliberation during the summer of 2022. OBJECTIVES: (1) To explore the perspectives of Quebec and Ontario citizens regarding tiebreakers, identifying the most acceptable ones and their underlying values. (2) To analyze these results considering other public consultations held during the pandemic on these criteria. METHODS: This was an exploratory qualitative study. The design involved an online democratic deliberation that took place over two days, simultaneously in Quebec and Ontario. Public participants were selected from a community sample which excluded healthcare workers. Participants were first presented the essential components of prioritization protocols and their related issues (training session day 1). They subsequently deliberated on the acceptability of these criteria (deliberation session day 2). The deliberation was then subject to thematic analysis. RESULTS: A total of 47 participants from the provinces of Quebec (n = 20) and Ontario (n = 27) took part in the online deliberation. A diverse audience participated excluding members of the healthcare workforce. Four themes were identified: (1) Priority to young patients - the life cycle - a preferred tiebreaker; (2) Randomization - a tiebreaker of last resort; (3) Multiplier effect of most exposed healthcare workers - a median acceptability tiebreaker, and (4) Social value - a less acceptable tiebreaker. CONCLUSION: Life cycle was the preferred tiebreaker as this criterion respects intergenerational equity, which was considered relevant when allocating scarce resources to adult patients in a context of extreme pandemic. Priority to young patients is in line with other consultations conducted around the world. Additional studies are needed to further investigate the public acceptability of tiebreaker criteria.

Evaluating the use of casuistry during moral case deliberation in the ICU: A multiple qualitative case study.

Intensive care unit (ICU) professionals engage in ethical decision making under conditions of high stakes, great uncertainty, time-sensitivity and frequent irreversibility of action. Casuistry is a way by which actionable knowledge is obtained through comparing a patient case to previous cases from experience in clinical practice. However, within the field of study as well as in practice, evidence-based medicine is the dominant epistemic framework. This multiple case study evaluated the use of casuistic reasoning by intensive care unit (ICU) professionals during moral case deliberation. It took place in two Dutch hospitals between June 2020 and June 2022. Twentyfive moral case deliberations from ICU practice were recorded and analyzed using discourse analysis. Additionally, 47 interviews were held with ICU professionals who participated in these deliberations, analyzed using thematic analysis. We found that ICU professionals made considerable use of case comparisons when discussing continuation, withdrawal or limitation. Analogies played a role in justifying or complicating moral judgements, and also played a role in addressing moral distress. The language of case-based arguments is most often not overtly normative. Rather, the data shows that casuistic reasoning deals with the medical, ethical and contextual elements of decisions in an integrated manner. Facilitators of MCD have an essential role in (supporting ICU professionals in) scrutinizing casuistic arguments. The data shows that during MCD, actual reasoning often deviated from principle- and rule-based reasoning which ICU professionals preferred themselves. Evidence-based arguments often gained the character of analogical arguments, especially when a patient-at-hand was seen as highly unique from the average patients in the literature. Casuistic arguments disguised as evidence-based arguments may therefore provide ICU professionals with a false sense of certainty. Within education, we should strive to train clinicians and ethics facilitators so that they can recognize and evaluate casuistic arguments.

The impact of misinformation presented during jury deliberation on juror memory and decision-making.

When deliberating, jurors may introduce misinformation that may influence other jurors' memory and decision-making. In two studies, we explored the impact of misinformation exposure during jury deliberation. Participants in both studies read a transcript of an alleged sexual assault. In Study 1 (N = 275), participants encountered either consistent pro-prosecution misinformation, consistent pro-defense misinformation, or contradictory misinformation (pro-prosecution and pro-defense). In Study 2 (N = 339), prior to encountering either pro-prosecution or pro-defense misinformation while reading a jury deliberation transcript, participants either received or did not receive a judicial instruction about misinformation exposure during deliberation. Participants in both studies completed legal decision-making variables (e.g., defendant guilt rating) before and after deliberation, and their memory was assessed for misinformation acceptance via recall and source memory tasks. In Study 1, misinformation type did not influence legal decision-making, but pro-prosecution misinformation was more likely to be misattributed as trial evidence than pro-defense or contradictory misinformation. In Study 2, pro-defense misinformation was more likely to be misattributed to the trial than pro-prosecution misinformation, and rape myths moderated this. Furthermore, exposure to pro-defense misinformation skewed legal decision-making towards the defense's case. However, the judicial instruction about misinformation exposure did not influence memory or decision-making. Together, these findings suggest that misinformation in jury deliberations may distort memory for trial evidence and bias decision-making, highlighting the need to develop effective safeguards for reducing the impact of misinformation in trial contexts.

Integrating online deliberation into ecosystem service valuation.

Stated preference valuation of ecosystem services involves participants answering hypothetical questions to express preferences. Participants tend to respond to the hypothetical questions separately, without any deliberation (the process of considering and discussing within a group). However, a relatively recent development in deliberation research involves asking participants to state preferences via deliberation. Deliberation is historically conducted in-person but can now also be done online. This paper covers the strengths and limitations of integrating online deliberation into stated preference valuation, including: (1) comparison between stated preference valuation with and without deliberation, (2) comparison between in-person and online deliberation, and (3) comparison between online deliberation media, such as typing, video meetings, and voice calls. Conducting deliberation can broaden participants' understanding of the target ecosystem services and others' preferences. However, this requires participants' willingness to deliberate and increases time investment. Online deliberation has lower costs and travel restrictions and higher time efficiency and confidentiality of personal information than in-person deliberation. However, people with low abilities or willingness to use online media are disadvantaged. Differences in the online deliberation media may reduce or improve the inclusiveness, engagement, and openness of deliberations in ways that affect valuation results. We also provide suggestions for selecting deliberation media and mitigating deliberation bias derived from the choice of deliberation media. Further research should explore how to improve time efficiency and affordability of online deliberation, how to promote inclusiveness, engagement, and openness of online deliberation, and how different deliberation media affect deliberation quality and valuation results.

Guideline panel social dynamics influence the development of clinical practice recommendations: a mixed-methods systematic review.

OBJECTIVES: To synthesize empirical studies that investigate the cognitive and social processes involved in the deliberation process of guideline development meetings and determine the distribution of deliberated topics. STUDY DESIGN AND SETTING: We conducted a mixed-method systematic review using a convergent segregated approach. We searched for empirical studies that investigate the intragroup dynamics of guideline development meetings indexed in bibliographic databases. RESULTS: Of the 5,899 citations screened, 12 studies from six countries proved eligible. Chairs, cochairs, and methodologists contributed to at least one-third of the discussion time in guideline development meetings; patient partners contributed the least. In interdisciplinary groups, male gender and occupation as a physician were positively associated with the amount of contribution. Compared to groups that used the Grading of Recommendations Assessment, Development and Evaluation approach, for groups that did not, when faced with insufficient or low-quality evidence, relied more on their clinical experience. The presence of a cognitive "yes" bias was apparent in meetings: panelists tended to acquiesce with positive statements that required less cognitive effort than negative statements. CONCLUSION: The social dynamics of the discussions were linked to each panelist's activity role, professional background, and gender, all of which influenced the level of contributions they made in guideline development meetings.

Assessing Facilitator Fidelity to Principles of Public Deliberation: Tutorial.

Public deliberation, or deliberative democracy, is a method used to elicit informed perspectives and justifiable solutions to ethically fraught or contentious issues that affect multiple stakeholder groups with conflicting interests. Deliberative events bring together stakeholders (deliberants) who are provided with empirical evidence on the central issue or concern and then asked to discuss the evidence, consider the issue from a societal perspective, and collectively work toward a justifiable resolution. There is increasing interest in this method, which warrants clear guidance for evaluating the quality of its use in research. Most of the existing literature on measuring deliberation quality emphasizes the quality of deliberants' inputs (eg, engagement and evidence of compromise) during deliberative sessions. Fewer researchers have framed quality in terms of facilitator inputs, and these researchers tend to examine inputs that are consistent with generic group processes. The theory, process, and purpose of public deliberation, however, are distinct from those of focus groups or other group-based discussions and warrant a mechanism for measuring quality in terms of facilitator fidelity to the principles and processes of deliberative democracy. In our public deliberation on ethical conflicts in minor consent for biomedical HIV prevention research, we assessed facilitator fidelity to these principles and processes because we believe that such assessments serve as a component of a comprehensive evaluation of overall deliberation quality. We examined verbatim facilitator remarks in the deliberation transcripts and determined whether they aligned with the 6 principles of public deliberation: equal participation, respect for the opinions of others, adoption of a societal perspective, reasoned justification of ideas, expression of diverse opinions, and compromise or movement toward consensus. In this tutorial, we describe the development of a blueprint to guide researchers in assessing facilitator fidelity, share 3 templates that will assist them in the task, and describe the results of our assessment of facilitator fidelity in 1 of the 4 sites in which we conducted deliberations.

Having a real say: findings from first nations community panels on pandemic influenza vaccine distribution.

BACKGROUND: Recent deliberations by Australian public health researchers and practitioners produced an ethical framework of how decisions should be made to distribute pandemic influenza vaccine. The outcome of the deliberations was that the population should be considered in two categories, Level 1 and Level 2, with Level 1 groups being offered access to the pandemic influenza vaccine before other groups. However, the public health researchers and practitioners recognised the importance of making space for public opinion and sought to understand citizens values and preferences, especially First Nations peoples. METHODS: We conducted First Nations Community Panels in two Australian locations in 2019 to assess First Nations people's informed views through a deliberative process on pandemic influenza vaccination distribution strategies. Panels were asked to make decisions on priority levels, coverage and vaccine doses. RESULTS: Two panels were conducted with eighteen First Nations participants from a range of ages who were purposively recruited through local community networks. Panels heard presentations from public health experts, cross-examined expert presenters and deliberated on the issues. Both panels agreed that First Nations peoples be assigned Level 1 priority, be offered pandemic influenza vaccination before other groups, and be offered two doses of vaccine. Reasons for this decision included First Nations people's lives, culture and families are important; are at-risk of severe health outcomes; and experience barriers and challenges to accessing safe, quality and culturally appropriate healthcare. We found that communication strategies, utilising and upskilling the First Nations health workforce, and targeted vaccination strategies are important elements in pandemic preparedness and response with First Nations peoples. CONCLUSIONS: First Nations Community Panels supported prioritising First Nations peoples for pandemic influenza vaccination distribution and offering greater protection by using a two-dose full course to fewer people if there are initial supply limitations, instead of one dose to more people, during the initial phase of the vaccine roll out. The methodology and findings can help inform efforts in planning for future pandemic vaccination strategies for First Nations peoples in Australia.

Deliberative Democracy and Incompatibilities of Choice Norms.

Deliberative democracy aims at reaching collective decisions through mechanisms that involve flexible opinions, variable alternative sets and information gathering in the process of decision making as opposed to exogenously fixed alternative sets and preference rankings. Deliberative democracy includes elements derived from bargaining and negotiation. Among its virtues, some proponents of deliberative democracy have included the possibility that several important negative results of the theory of voting can be avoided. The basic stratagem is to dismiss the universal domain condition typically assumed in social choice results. Thus, the validity of the results escaped from is obviously not in question. The position taken in this paper is that, while in some respects plausible, the escape argument is based on a too narrow view of the incompatibility results of the social choice theory. Some fundamental paradoxes remain beyond the reach of the deliberative techniques and are even exacerbated by them. That said, the deliberative approach can certainly be adopted for making voting alternatives more meaningful to those involved.