Introduction

Is the "ordinary"[1] citizen a simple consumer of goods and decisions or can he be considered an actor responsible for his actions? Can individual citizens be considered as social actors similar to other collective participants, such as experts and decision-makers? What resources are or can be allocated to citizens? Is direct democracy preferable (citizen =  social actor) to elective democracy (citizen = individual), i.e. is it preferable to allow the people susceptible of being affected by a decision to take part in the decision or rather is it better for them to delegate this right to elected representatives? The legitimacy of the public’s right to be consulted and to participate is acquired within western societies (Parenteau, 1988; CSQ, 1993; TRNEE, 1993; Renaud, 1994; Séguin, De Coninck & Tremblay, 2005). The extent and form of citizen participation and type of follow-up to decision-making processes still constitute major areas of debate.

Consider, for example, two sectors that illustrate the need for involving citizens: the environment and public health. In 1986, the Brundtland Report (1987) redefined the justification frameworks by introducing the concept of "sustainable development". Since then, it is recommended that decision-making processes reconcile the economy with a respect for the environment and the well-being of society. Moreover, according to Brundtland, the respect of equity is applicable on several levels; across generations, among regions, and among societies. Finally, when respect for nature and its resources, a healthy living environment, and the right of future generations to benefit from these will be considered, the qualitative aspects of development will be privileged over its quantitative aspects. This environmental framework therefore asks decision-makers, in its own specific way, how, for whom and why a decision is made.

Public health recognizes that the health of any population is closely related to its living conditions and that this ultimately depends on a multitude of interventions evolving as much from within than without the traditional sphere of health concerns, i.e. education, employment, leisure, economy, environment, etc. Consequently, it is important to recognize the contribution of the various types of partners with whom participants and decision-makers can compromise in order to support the groups, the communities and the individuals in the realization of their ambitions, the satisfaction of their needs and the challenges that they are confronted with in their milieus. Based on this perspective that is well documented in the Ottawa Charter for health promotion (OMS, 1986), health is a part of everyday life and for it to flourish implies a certain emancipation of individuals so that they can develop their capacity for a full life. To ensure the conditions allowing this emancipation, the participants and the decision-makers must seek to understand the expectations, the needs and the competencies of people and their milieu. And this knowledge cannot truly prevail unless there is the establishment of partnerships and exchange relationships, beyond traditional approaches whereby professionals are the unidirectional provider of services.

Democratizing decision-making processes

Democratizing decision-making processes assumes a diversity of interests and ideas. But it is not limited to a consultation and a participation structure whereby ordinary citizens confirm the choice of a solution suggested by decision-makers (Freire, 1980; 1998). It can also consider their implication from the beginning of the decision-making itself and, consequently, allow the consideration of what is "causing a problem" according to different participants. At this level, the values, the interests and the experiences of each can contribute greatly.

Consultation must be seen not only as a decision-making aid, but also as a new potential space of social change. According to Hamel, consultation "participates towards the transformation of social relationships and relationships of power in a direct way" (Hamel, 1997, p. 418[2]), a point of view shared by several other authors (Callon, Lascoumes & Barthes, 2001, for exemple). However, if consultation is to be effective, it cannot just look good on paper or as simply part of what an institution does. As Theys explains (free translation,2003, p. 23): "All the efforts regarding `institutional design' are likely to prove insufficient if they are not accompanied, in parallel, with a certain number of actions seeking to improve the equilibrium of the power struggle among stakeholders ". It is in this context that the following question can now be better understood: why informed consensus?

Informed consensus

According to Morel (2000), informed consensus:

is part of a global process questioning scientific and technical issues. In the past ten years, about thirty informed consensus conferences have taken place in twelve countries (...) Furthermore, this mode of public participation is not the only type which has recently been experimented with. (free translation, p. 805)

Consultation by "informed consensus" has quickly become a method permitting a high degree of participation and responsibilisation of ordinary citizens within a process that deals with issues concerning them (Roqueplo, 1997). It implies a progressive process of deliberation whereby alternate personal reflections, exchanges within a small group, as well as dialogue with experts and the public are conducted before a final position is adopted in an independent and transparent process (De Coninck et al. 1997; De Coninck et al.,1999). This process makes it possible to incorporate civic participation in professional and political decisions from the very start, in opposition to traditional closed-door processes. It is inspired by and derived from “conference consensus development” which was applied for the first time in 1977 in the United States by the National Institute of Health (Fink, Kosecoff, Chassin & Brook, 1984; Andreasen, 1988).

This technique of consultation can be viewed as a revitalization of the concept of the democratic forum (Roqueplo, 1997, quoting Donnet-Kamel, 1996). From a more general point of view, consultation by informed consensus constitutes a tool part of larger evaluation processes. The recommendations that conclude such an exercise are not legally binding. They enrich decision-making processes for decision-makers and are advisory. They can contribute to reinforcing adherence to a policy, act as a framework of reference, highlighting the elements characterizing the decision itself; but they cannot claim to replace the decision-making process itself. The informed consensus approach seeks to go beyond a collection of individual expert judgments by providing a collective response from a concerned community of citizens seeking to determine the practical values of the proposed decisions and solutions (Giraud & Jolly, 1991). It acts as a group judgment, of which each element has been informed; and essentially it is this that confers it a qualitative legitimacy.

Informed consensus requires that citizens who are at the helm of the process do not have a direct interest in the issue under study. They are presented the basic elements of the issue on which they are consulted. They then determine the questions that need to be addressed, ask experts to answer them and then hold public debates (they do this alone or with assistance). Informed consensus gives citizens a voice and makes it possible to maintain an informed debate on specific and complex problems that concern them in one way or another (De Coninck et al., 1997).

The informed consensus conference is necessarily situated upstream of the decision-making process of decision-makers, such as elected officials or industrial leaders, in order to enlighten them. As with any consultation results, the decision-maker who refuses to take the advice or who endorses it must defend and justify his or her choice. With informed consensus, this justification can become part of a broader social space created because of the contribution of citizens, which can be unique and related directly to this type of consultation.

Informed consensus thus reverses the traditional approach of the relationship between the expert/commissioner and the citizen. The citizen becomes the “commissioner” of the consultation and it is the experts that must explain, defend, and justify their point of view to the public, which is not the usual way to proceed in public consultation.

A democratic decision-making process should seek to maximize social consensus regarding a program, a policy or a local project and therefore should seek to involve the main participants in the decision-making and management processes linked to the program, the policy or the local project under study.  It would therefore seek to integrate not only decision-makers, experts and interested stakeholders that have clear ties to the issue, but also community groups and ordinary citizens that will eventually be directly or indirectly affected by the decision. According to this approach (that is still not very widely put into practice), social acceptability should rest on the acceptability of a common definition of the stakes and interests involved in an issue rather than simply on the choice of a specific solution that has been defined beforehand by experts and decision-makers within closed-door processes. Because the basis for decisions are not explicitly stated, the traditional approach places citizens in a de facto position of reaction and opposition. By involving the citizen more upstream in the decision-making process, such a framework of dialogue moves the citizen forward as a partner and not as a customer who can only adhere to or oppose.

The informed consensus conference enriches economic and techno-scientific choices by social and environmental considerations. It contributes to the widening of knowledge and of the social space surrounding decision-making processes. The citizen committee expresses criteria of design, of context and of choices within issues and they can then be considered as priorities to integrate within forthcoming decisions. By doing this, it contributes to the foundational development of a collaborative process among partners for formulating more harmonious action plans, proposals and projects.

Consulting citizens and involving them in a process of information-consultation and participation in decision-making processes is not necessarily “neutral”. From the actions undertaken, it is possible that any consultation of this type will generate "effects of overflow" (Callon, 1997) not foreseeable at the moment of its realization. However, its potential to enrich decision-making is too important, making it a tool of choice that seeks to contribute to the resolution of multidimensional ecological, economic, technological and social issues (TRNEE, 1993).

Conclusion

What were the reactions and the repercussions of our presentation of informed consensus at JASP? There was initially an enormous interest on behalf of the participants in the workshop. There was then a participant from France who wanted "to put into practice the Quebec version" of this approach as soon as she returned. A consultant met with the authors to discuss the possible use of this approach in the Montreal district to help determine investment priorities for community health. Other public health professionals asked the lecturers if they would agree to present this conference again in front of those responsible within their hierarchy. Meetings also took place with an office of public consultation in order to explore this type of alternative. Lastly, the preparation of an “Informed consensus conference practice guide”, expected for summer of 2007 (which could certainly interest participants at the Vancouver conference), should help to provide information to others on this relatively new way of consulting, thus making it possible to contribute to social solidarity while working on the challenges concerning public health environmental and community issues.

References