## Introduction

An often under-appreciated practical problem in the instantiation of deliberative forums is how to recognise endpoints of collective decisions. The challenge here is not only to ascertain the degree of support that is present for a particular position among a group, but also which reasons to attach to the collective decision. Deliberation, as envisaged by most theorists and practitioners in the field, involves detailed and iterative conversations among diverse participants. Participants are expected to listen carefully to each other and be willing to change their positions in light of new information or hearing the perspectives of others (Chambers 2003). Therefore, over the course of deliberation, various positions and reasons for those positions are offered, considered, rejected, amended and supported. In all of this, how—specifically—should a final position be recognised? Of all the reasons discussed, which ones should be recognised as substantively associated with such a final position or decision?

Moore and O’Doherty (2014) proposed the use of deliberative voting as a means to recognise such end points of deliberation and to solicit key reasons from participants for supporting (or rejecting) such collective decisions. In deliberative theory, voting is often seen as aggregative and devoid of public reasons, whereas deliberation is seen as rich and nuanced and providing a mechanism that allows the interests of diverse individuals and groups to be taken into account in developing a collective decision (Chambers 2003; He & Warren 2011). The concept of deliberative voting is distinctive in that it offers the use of a voting procedure within deliberation, not as a way to aggregate and fix a final collective decision, but rather to make visible the degree of acceptance of a position within a deliberating group and the reasons deliberators have for accepting or rejecting the position.

The purpose of this study is to build on the proposal by Moore and O’Doherty (2014) to integrate deliberative voting in deliberative processes. In particular, we provide an analysis of transcripts from a public deliberation on cancer drug funding policy to gain a deeper understanding of the discursive dynamics of deliberative voting and to further develop our theoretical understanding of the function of embedding voting procedures in deliberative processes. In our analysis, we begin with the premise that the process and outcomes of deliberation are influenced by several contextual factors, including the facilitator of the deliberative process, structural and design elements, and the actual statements made by deliberants. We thus understand deliberative voting not as a technical procedure that measures a social fact in a straightforward way, but rather as a discursive phenomenon that is the result of contingent factors in the deliberative environment. Conceptualizing deliberative voting as a discursive phenomenon allows us to examine how participants use the vote as a social action to articulate complex disagreements, and analyze how disagreement impacts the deliberative process. To illustrate the utility and operation of deliberative voting, we present an analysis of transcripts from a public deliberation about public funding for cancer drugs that was held in Canada in 2016. We use discursive psychology as a methodology to guide our conceptualisation of deliberative voting as a communicative act and as an analytical framework to guide our analysis of the deliberation transcripts.

## Deliberation and Deliberative Voting

During deliberation, participants are encouraged to identify personal values, interests and opinions, highlight potential trade-offs, and test competing moral claims (Blacksher et al. 2012). With the help of a facilitator, participants are asked to build recommendations that may help inform policymakers about the issue (Burgess et al. 2008). The facilitator works with participants to find common ground while ensuring pluralism of different perspectives and arguments (Blacksher et al. 2012; Landwehr, 2014; Mansbridge et al. 2006).

If the goal of deliberation is for participants to cultivate a mutually shared position on the issue at hand (O’Doherty 2013), then how do facilitators and participants recognise when a shared position has been reached? This is an under-appreciated and non-trivial question in the implementation of deliberative ideals. In the public deliberation that is the focus of this analysis, participants engaged in collectively developing recommendation statements and then voting on them. We explore how facilitators impact the process of deliberative voting and identify how participants use deliberative voting to express three types of disagreements with the recommendation statements; these are categorized as actual disagreements, nuanced disagreements and marginal disagreements (Moore & O’Doherty 2014).

At the public deliberation, 24 participants collectively developed 16 recommendation statements with the help of a trained facilitator. The full list of recommendation statements developed in this public deliberation is provided in Appendix A. After each recommendation statement was produced, the facilitator called a vote during which participants were given three choices; they could choose to support the recommendation, reject the recommendation, or abstain. This vote was made publicly using iClicker devices (Figure 1). The iClicker technology automatically tallied each of the votes and displayed the results at the front of the room onto a projected screen. Participants were instructed to click A for yes, B for no, and C to abstain. Following the vote, the facilitator asked participants to provide the reasons supporting their vote, which in turn could lead to more discussion, refinement of the recommendation statement, and further voting. This voting process is therefore iterative in the sense that the vote does not necessarily signal the end of the discussion; the discussion may move back and forth between deliberation and voting. Moore and O’Doherty (2014: 312) use the term deliberative voting to signal that this practice of voting is ‘embedded within a deliberative process’, not an aggregative tool to simply tally personal preferences.

Figure 1

The iClicker device used for deliberative voting.

O’Doherty (2013) explains that the process of deliberative voting serves multiple purposes. First, the vote works as a facilitation tool. The vote allows the facilitator to gain a clear indication of which participants agree and disagree with the recommendation statement. Rather than simply assuming that participants have reached a consensus, the vote allows the facilitator to see where there are agreements and disagreements; thus, the facilitator ensures that the deliberating group hears dissenting and marginal views. If minority views are not incorporated in final recommendation statements, the facilitator can ensure that they are officially recorded (Moore & O’Doherty 2014). Deliberative voting can also signal the closure of the discussion of a particular issue, allowing for a clear transition onto the next topic. In this sense, the vote provides the facilitator with the opportunity to ‘obtain clear documentation of divergent views and the reasoning of both majority and minority perspectives’ (O’Doherty 2013: 11). The function of the voting process is that it helps to ‘identify and preserve discursive diversity, even within a deliberative process that itself involves the creation of common ground and the reduction of discursive diversity to a single proposition that can be endorsed by the group’ (Moore & O’Doherty 2014: 317).

The process of voting and the associated practice of having dissenters and abstainers explain their reasons allows those who disagree with the majority position to have their views heard by the group and officially documented. The recommendation statements and the associated votes and reasons make up the official results of this public deliberation event. O’Doherty (2013) refers to these as the deliberative output, which is defined as ‘an explicit collective statement of deliberants about a position or policy preference’ (O’Doherty & Burgess 2009: 7). Deliberative voting is not simply a tool for aggregate decision making; instead, it is a process that is integrated into the deliberative conversation.

## Framing and Facilitation

There are contingencies in deliberative processes that play a role in how conversations unfold and the ultimate outcomes of the deliberation. Arguably, the most notable are the framing of the topic of the deliberation and the actions of the facilitator(s).

The way a deliberation is framed by those who design and facilitate the event will impact both the process and outcomes. Thus, organizers have the ‘communicative power to structure the context of a given deliberation’ (Barisione 2012:1). They establish the legitimacy of various viewpoints, drawing attention to certain aspects of the issue, and emphasize some aspects of the topic over others (Barisione 2012; Calvert & Warren 2014).

How issues are framed for a deliberation will also influence policymakers’ ability to take up recommendations made during the event. Therefore, involving decision-makers in the framing of issues and the formulation of questions for deliberation may be both warranted and effective in translating the outcomes of deliberation into policy. At the same time, deliberative practitioners and policy experts should recognize that their understanding of the issue may differ from the participants (O’Doherty & Hawkins 2010). MacLean and Burgess (2010) suggest that deliberative organizers can find a balance between constraining conversation within the provided frames while simultaneously allowing for the discussion of spontaneous topics introduced by participants. However, participants who wish to challenge the framing of the issues or express alternative, unpopular perspectives may have their views marginalized by other participants and or the facilitator (Kerr et al. 2007). To address this, facilitators may explicitly note that the framing of issues and questions for deliberation is not final and is itself a legitimate topic for deliberation (O’Doherty & Hawkins 2010).

The facilitator is an active participant in the deliberative conversation while simultaneously being an integral part of the event’s structure (Moore 2012: 147). Thus, the facilitator has an important role in framing the conversation topics and guiding the voting process. However, the facilitator’s role in deliberation is often overlooked in both the theoretical and empirical literature on deliberation (Landwehr 2014; Smith 2009; Chilvers 2008; O’Doherty & Hawkins 2010).

In the analysis below, we examine the discursive dynamics of deliberative voting to further develop our theoretical understanding of the function of embedding voting procedures in deliberative processes. We explore how participants use deliberative voting as a communication tool to signal disagreement. We pay particular attention to the role of the facilitator in the deliberative voting process, and the role of the voting process in shaping the conclusions of the deliberants (i.e., the deliberative outputs).

## Method

### Cancer Drug Funding Decisions

The data examined in the current study comes from a more extensive project relating to cancer drug funding in Canada (Bentley, Abelson, Burgess, et al. 2017; Bentley, Costa, Burgess, et al. 2018; Costa et al. 2019). A series of six deliberations on funding for cancer drugs were conducted across different regions of Canada between April and October, 2016. The project was funded by The Canadian Partnership Against Cancer.

Cancer is the leading cause of death in Canada (Statistics Canada 2020). The Canadian Cancer Society (2018) estimates that in Canada, there were 206,200 new cancer diagnoses in 2017 and that 80,800 people died from cancer that year. At the same time, research has led to many new cancer drugs that, while often more effective for a small proportion of patients, are much more expensive than traditional treatments. Thus, in addition to a rise in cancer incidence, the cost of new cancer drugs is leading to a potentially unsustainable funding situation. The organizers of the deliberation sought to enhance the range of meaningful and informed public values and perspectives available to policymakers responsible for making decisions about cancer drug funding. Participants in the deliberations were thus asked to develop a series of recommendations as input for policy decisions aiming to equitably allocate the limited financial resources available to fund cancer drugs.

Bentley and colleagues’ (2017) Final Report of this project provides a detailed description of the recruitment, methodology and event procedures. The project consisted of six public deliberation events across different regions of Canada. Our analysis is based on the transcripts of one of these public deliberations, which was conducted in Halifax, Nova Scotia. We were both involved in various aspects of the larger project (for example, as small-group facilitators). At the Halifax deliberation, we did not take an active role in the proceedings and were present only as observers. We therefore chose this particular deliberation as the focus of our analysis.

### Deliberation structure

The deliberation took place over a two-day weekend in May 2016. Prior to the event, each participant was sent a Citizen Brief (Wilson et al. 2016) that outlines key information and perspectives relevant to the deliberation topic. At the start of day one, participants were presented with a variety of expert perspectives on the topic. These included a video created for the event that introduced perspectives from physicians, a health economist, and a Canadian Cancer Society CEO. Two local presenters also spoke with participants about the context and issues specific to Nova Scotia. The presenters were a local surgeon and medical director, and a cancer survivor.

Throughout the event, participants moved between small-group discussions and large- group deliberations. In small groups, deliberants explored a broad range of perspectives and positions. The purpose of the small groups was to get participants comfortable with the topic and talking to each other. At this point, there was no aim to work towards consensus but rather to explore the topic, hear the views of different participants, and get comfortable expressing perspectives. Participants engaged in a variety of small-group activities including listing their hopes and concerns about how new cancer drugs will be funded, and exploring their personal values by making difficult financial trade-offs for cancer drug funding. Small-group facilitators were instructed to encourage open dialogue, and avoid having the participants draw conclusions (Bentley et al. 2018).

In the large-group, the purpose shifted to developing recommendation statements for policymakers with the help of a facilitator. The facilitator followed the form of deliberative voting described above. Directly following each vote, the facilitator asked the participants who disagreed with the recommendation to provide reasons for their position. The results of the vote and the reasons given by those who voted against or abstained from voting were officially documented in the deliberative outputs that were distributed to policymakers following the deliberation event (see Bentley et al. 2017). This method is a particular instantiation of the deliberation process developed by Burgess, O’Doherty and colleagues (see, e.g., Burgess, O’Doherty, & Secko 2008; O’Doherty & Burgess 2009; Burgess, Longstaff, & O’Doherty 2016).

### Participants

Participants were recruited using an online market research company. Twenty-four Nova Scotia residents participated in the two-day deliberation. Participants were selected to represent demographic diversity of the province. More details can be found in Bentley et al. 2017. Table 1 displays participants’ demographic information.

Table 1

Participant characteristics.

Characteristic %
Age
25–35 25%
35–49 21%
50–64 25%
65 and over 29%
Gender
Female 46%
Male 54%
Income
Less than $20,000 4%$20,000–$49,999 50%$50,000–$79,999 25%$80,000 or above 4%
No response 17%
Highest Level or Education Achieved
High School 13%
College or Apprenticeship 17%
Some University 21%
University or above 50%
Ethnic Background
Aboriginal 4%
Black 13%
Chinese 13%
Filipino 4%
Latin American 4%
South Asian 8%
White 50%
Other 4%
Experience with Chronic Disease
Experience with chronic disease (personal or as a caregiver) 54%
• Note: Total N = 24.

Each participant received an honorarium of $125 per day (to a maximum of$250). Additionally, all expenses, including travel, accommodation and meals were remunerated. All participants consented to participate. Following the ethics protocol, all of the information presented here has been anonymized to protect participants’ confidentiality. All participants are referred to by pseudonyms.

This deliberation event received ethics approval from BC Cancer Agency Research Ethics Board, the University of British Columbia and Simon Fraser University Research Ethics Boards. The Research Ethics Boards at the University of Guelph and the University of British Columbia granted ethics approval for the current study.

### Discursive Psychology

During the deliberation, participants are responsible for weighing the validity of the arguments that are presented by their fellow deliberants (Moore & O’Doherty 2014). However, the strength and validity of these arguments are situated in the event’s social and historical context (O’Doherty 2017). The purpose of this analysis is not to evaluate the quality of the various reasons and warrants that are made during the deliberation, but rather the ways in which deliberative voting can be used as communicative action to shape the processes and outcomes of deliberation. The deliberative outputs are influenced by social processes, contemporary political debates, dominant discourses, and the prevalent values (such as religious or cultural values) of the time. Our analysis is thus premised on understanding statements of participants not as representations of their cognitive states, but rather as part of an ongoing social negotiation of values and interests. As such, statements of participants need to be understood for the rhetorical force they represent, and the way they shape the subsequent evolution of the discourse of the deliberation.

In adopting this position, we are guided by the principles of discursive psychology. Discursive psychology is both a theoretical and a methodological framework for social psychological inquiry (Potter & Wetherell 1987). As an approach to studying language use, discursive psychology stands in opposition to cognitive psychological approaches. Potter (1996) argues that when we conceptualize language use as internal, we fail to understand the social actions that are being accomplished through its use in situ, in the contexts and interactions where meaning and representations are produced. Whereas cognitive approaches take internal psychological phenomena as their objects of study, discursive approaches analyze how language is used on the level of interaction, as a social phenomenon (Hepburn & Wiggins 2005). Discursive psychology is an approach to discourse analysis that has gone through many iterations and changes. As we aim to investigate how participants use deliberative voting as a social action on the micro-level within deliberative conversations, we draw specifically on the work of Potter and Wetherell (1987) and Potter (1996) to conduct this analysis. This form of analysis is effective for understanding how refusals are enacted in situ at the level of individual interaction (Kitzinger & Frith 1999; Potter & Wetherell 1987). Kitzinger and Frith (1999) argue that ‘refusals are complex and finely organized interactional accomplishments’ (p. 299). This analytic framework allows us to investigate how disagreement and refusal are signalled and accomplished within the deliberative voting context.

Deliberative voting is a mechanism that allows for disagreement and refusal to become publicly visible and therefore to be part of the ongoing deliberative dynamics. Voting is helpful because it enables us to conceptualize the act of disagreement through an explicit social action and analyze the consequences for the deliberative process. By conceptualizing the ‘no’ votes and abstentions as social actions, we can use a discursive psychological approach to examine the transcript and identify how disagreement and refusal happen and the social consequences of deliberative voting.

### Types of disagreement

We examined the transcripts from the two-day event to document every instance when a participant voted against a recommendation statement or abstained from voting. We then used a discursive psychological approach and Moore and O’Doherty’s (2014) framework to analyse the conversation following the vote to understand how participants used this deliberative voting process to signal disagreement. Moore and O’Doherty’s (2014) framework outlines three types of articulations that participants might offer when asked why they voted against a statement or abstained: actual disagreements, nuanced disagreements and marginal disagreements.

First, actual disagreements are based on fundamental value differences that were not overcome, despite the participants’ and the facilitator’s efforts to find common ground. Second, nuanced disagreement occurs when participants seek clarification of particular details to increase the precision of the wording used in the statement. Finally, marginal disagreements occur when ‘the dissent takes the form of a qualification that cannot easily be incorporated into the statement, but also does not constitute actual disagreement with the proposed collective statement’ (p. 316). In the following analysis, we use these three categories as a framework to examine how participants in this deliberation use the process of deliberative voting as a communication tool.

## Analysis

We now demonstrate how the three types of disagreement play out in the deliberation. When viewed as a social action, it becomes evident that participants use the vote to disagree or abstain in rhetorically diverse ways. These rhetorical functions can be roughly fit into the typology of actual, nuanced and marginal disagreements. Additionally, when viewed as a social action, we can analyze the discursive consequences of the unfolding deliberation that have been made visible by the vote.

### Actual Disagreement

Throughout the public deliberation event, when participants were asked to share the reason why they voted against a recommendation most constituted actual disagreements. The following excerpts illustrate examples of this form of disagreement. In excerpt one, Lillian articulates her disagreement with recommendation 10, which states: ‘Processes used to make drug funding decisions should be transparent, so the public understands how decisions are made and who is making them.’ Lillian is asked to explain why she voted against the recommendation.

Excerpt 1

LILLIAN: Myself as part of the public, I would not understand how the decision is made. I wouldn’t understand.

FACILITATOR: Okay.

LILLIAN: It’s just that I’m not qualified. That’s why I have the hope that the committee themselves, who are qualified medical professional, whatever, makes up the whole committee, they’re going to make the decision in my best interest.

FACILITATOR: Okay. So, in other words, just to make sure I’m understanding what you’re saying: Look, you can make this transparent, but I’m not necessarily going to be able to understand.

LILLIAN: I’m just a layman, I don’t understand what you’re making, as long as whatever decision you’re making is going to be in my best interest.

FACILITATOR: Right.

LILLIAN: I leave it up to you.

Lillian describes herself as unqualified to understand how drug funding decisions are made. Lillian refers to herself as ‘part of the public’ (line 1) and as a ‘layman’ (line 10). These descriptions work to position Lillian as passive and unqualified; she says, ‘I would not understand how the decision is made’ (lines 1–2). Lillian contrasts her position of being an unqualified layman with a depiction of committee members as ‘qualified medical professional[s]’ (line 5). Committee members are described as being responsible for making decisions for the public; she says: ‘I leave it up to you’ (line 11).

Lillian suggests that medical professional committee members are responsible for working in the best interest of the public. Lillian repeats this phrase twice in her description: ‘in my best interest’ (lines 6 & 11). Lillian creates a dichotomy between herself as a passive and unqualified layman and expert committee members. Her articulation suggests that drug funding decisions should be within experts’ jurisdiction not the general public.

In Excerpt 1, the facilitator works to clarify Lillian’s argument by rephrasing the argument and presenting it back to Lillian for verification. The facilitator says: ‘So, in other words, just to make sure I’m understanding what you’re saying: Look, you can make this transparent, but I’m not necessarily going to be able to understand’ (Lines 7–9). According to Landwehr (2014), the role of the facilitator is to ensure that a plurality of views are expressed and considered. When the facilitator helps the participants clearly articulate the justifications for their votes, it works to ensure that the participants’ dissenting views are accurately documented in the deliberative outputs. Voting against this recommendation allowed Lillian to have her reasons for disagreeing heard by the group of deliberants. Voting in this way also ensured that her disagreement was officially documented alongside the recommendation statement.

Excerpt 2 shows how Sam uses the reason giving period to articulate his disagreement with recommendation seven: ‘Evidence of effectiveness must be based on full disclosure to the regulator of clinical trial sample characteristics, full datasets, and it should be peer reviewed.’

Excerpt 2

FACILITATOR: Okay, yeah. Why no?

SAM: I wouldn’t want this recommendation to stand in the way of a pharmaceutical company potentially bringing a promising drug to market.

FACILITATOR: Okay. I think that’s a really good—that’s a really important to put in here. That we understand that there’s a tradeoff and that some of us are like no, I’m not going to make that tradeoff. Okay.

Sam’s description of the potential for regulation and mandatory reporting to impede pharmaceutical companies bringing drugs to market portrays the process of full disclosure as an impediment to medical progress. This articulation works to construct a dichotomy between regulation and progress. Sam’s ‘no’ vote signals his preference for getting drugs to market over full disclosure to a regulator. The facilitator supports Sam’s position in her reply, ‘we understand that there’s a tradeoff and that some of us are like no, I’m not going to make that tradeoff’ (lines 5–6).

Similar to Excerpt 1, the facilitator validates Sam’s dissenting view and supports the documentation of this perspective as an addendum to the recommendation statement. She says: ‘that’s a really important to put in here’ (line 4). The facilitator calls Sam’s disagreement ‘good’ and ‘important’, and verifies that it will be ‘put in’ to the outputs alongside the recommendation. These statements encourage participants to express views that may be counter to the majority perspective. This works to support a balanced and inclusive environment that allows for equal participation (Landwehr 2014).

To sum up, many of the participants who voted against recommendations, or abstained from voting, expressed actual disagreements in the post-vote reason giving discussions. In almost all instances, the expression of actual disagreement did not lead to a revision of the recommendation statement. Nevertheless, these discussions allowed participants an opportunity to articulate their disagreements to the group of deliberants and to have them documented. Expressing actual disagreements gave participants with minority views an opportunity to have these views represented in the deliberative outputs. In these excerpts, the facilitator provided supportive statements that worked to validate the participants’ dissenting views as valuable and worth including in the deliberative outputs. However, as we will show in the following examples, this is not always the case.

### Nuanced Disagreement

In this section, we examine participants’ use of deliberative voting to signal nuanced disagreement with particular details of the recommendation statements. As described above, in these instances participants advocate for increased specificity of the wording and particular details to be included in the statements.

The following excerpt shows how Hua used the ‘no’ vote to signal disagreement about the scope of recommendation statement 15 (‘Priority should be given to cancer drugs that improve access to treatments where access is poor.’). Hua does not fundamentally disagree with the direction of the statement; rather, she uses her vote to indicate that the wording of the statement should be broadened to include a greater population.

Excerpt 3

HUA: I kinda, like, already stressed my point. Basically I think as long as it’s improve—well, assuming the two drugs are—all the other factors are the same, then I think as long as it is improved the access to treatment for any patient, I think we should take priority for it, not just only consider when the access is currently poor.

Hua explains that she voted against this recommendation because she disagreed with the phrase at the end of the statement: ‘where access is currently poor.’ She argues that if the drug ‘improved the access to treatment for any patient, I think we should take priority for it’ (line 3). Hua’s description works to construct the recommendation statement as too narrow, and she says that access should be improved broadly, ‘not just only consider when the access is currently poor’ (line 4). Hua voted against the statement because the wording was too restrictive, and she argues that the recommendation should be broadened to include improvement for ‘any patient’ (line 3).

If one were only to look at the results of the vote, and not the reason-giving that follows, it would appear that Hua disagrees that access should be improved. However, when we read Hua’s explanation we see precisely the contrary. Hua voted against the statement because the description of improved access in the recommendation was too restrictive. She wanted access to improve for all patients, not just those for whom access is currently poor. This ‘no’ vote does not indicate an actual disagreement with the statement; instead, it works to add greater specificity to the recommendation by indicating to whom specifically improved access to treatment should be targeted (‘any patient’).

In the next excerpt, Janet describes why she abstained from voting on recommendation 11: ‘Trustworthy drug funding decisions should not require patient members on their committees.’

Excerpt 4

JANET: I abstained because I had the same problem in our group. I’m kind of on the fence of whether—I think definitely survivors should be included but I don’t know if a current patient is in the mental state to make the decisions. And I think that’s where I’m coming from. I definitely think survivors should be included. But I don’t know if a current patient would be in the right mental state to make that type of decision.

Janet abstained because she is ‘on the fence’ (line 1) about whether or not she agrees with the recommendation. Although Janet states that cancer ‘survivors should be included’ (line 2) on drug funding committees, she does not know if ‘a current patient would be in the right mental state to make that type of decision’ (lines 4–5). Janet’s reference to the ‘mental state’ (used twice) of current patients is used to justify claims about patients’ inability to make decisions about funding for cancer drugs. This description works to minimize the decision-making capacity of people who are currently experiencing cancer. Simultaneously, Janet works up a representation of former patients that maximizes their value and faculties. Former patients are referred to as ‘survivors’ who should ‘definitely’ be included in decision making.

Janet abstained from voting on this recommendation because the wording ‘patient members’ did not provide enough detail regarding what stage in their cancer journey these members would be. She did not disagree with the notion that people who have personal experience with cancer should be included in decision-making processes. Instead, the abstention signaled a lack of specificity in the recommendation between people who are survivors of cancer and people who are current patients.

In the next excerpt, Graham explains why he abstained from voting on recommendation 12: ‘Trustworthy drug funding decisions should not require members of the general public as participants.’

Excerpt 5

GRAHAM: I think it’s more the wording of the question than anything else. I think drug funding decisions shouldn’t require members of the public, but I think that it does. It think it makes the decision makers more accountable to have us there.

FACILITATOR: So you think that they should be a part?

GRAHAM: It’s more the wording of the question. Like I feel like it shouldn’t need people to be there to hold them accountable to make the decisions more—do you know what I mean?

FACILITATOR: Yeah.

GRAHAM: But I feel like it—that we do need it.

FACILITATOR: So really we shouldn’t need this in a perfect world but we do need it?

GRAHAM: Yeah.

Graham abstained in response to the ‘wording of the question’ (lines 1 & 5). He implies that decision-makers may be untrustworthy. Distrust is worked up through the suggestion that having members of the public present would increase accountability. The criticism of decision-makers is emphasised by normative claims by both Graham and the facilitator. Articulations are made about what ‘should’ and ‘shouldn’t’ be the case; ‘funding decisions shouldn’t require members of the public, but I think that it does’ (line 2). These statements work to construct decision-makers as failing to fulfill their obligations to members of the public, in instances where members of the public are not present to hold them accountable. Graham’s abstention gives him space to critique the statement’s wording and also the overall trustworthiness of decision-makers.

In summary, deliberants used deliberative voting to express nuanced disagreements relating to concerns about the wording, scope, and specificity of recommendation statements. Nuanced disagreements were more likely than actual disagreements to lead to a revision of the wording of the recommendation statement. This reflects the iterative nature of deliberative voting where the group discussion advances through a continual process of crafting, voting, and revising statements.

### Marginal Disagreement

Finally, we identified instances in which participants in this deliberation used deliberative voting to articulate what Moore and O’Doherty (2014: 216) describe as ‘qualification[s] that cannot easily be incorporated into the statement, but also [do] not constitute actual disagreement.’ Several participants used the process of deliberative voting to communicate disagreement with the usefulness or necessity of recommendation statements. In these instances, the participants abstained because they regarded the recommendation as redundant.

Excerpt 6 shows Oscar explaining his position as the only participant to not vote ‘yes’ on recommendation nine: ‘Life extension is valuable, provided there is reasonable quality of life.’ He explains why he abstained:

Excerpt 6

OSCAR: All right, so I abstained because while I believe it’s important to provide that context that Marvin was mentioning, and I abstained from voting on the statement because I feel that that was already a common understanding from a previous recommendation.

Oscar provides two reasons for his abstention: ‘it’s important to provide that context that Marvin was mentioning’ (line 1–2), and ‘there was already a common understanding from a previous recommendation’ (line 3). Oscar refers to an additional context that was given about the topic by Marvin, one of the principal investigators (PIs), during the discussion that led to the formation of this recommendation. Oscar argues that because this context did not make it into the final wording of the statement, he abstained. Oscar criticizes the statement for not providing sufficient detail to convey the participants’ position to policymakers adequately. Oscar also discusses a ‘common understanding’ (line 3) from an unspecified previous statement. These descriptions work to construct the recommendation statement as redundant. This description also suggests that the recommendation statements are not free-standing entities, but rather hang together and perhaps build off of one another. Given a previous recommendation, this statement is redundant.

In the next excerpt, we examine the reasons that Emerson and Wyatt report for abstaining from recommendation two: ‘We should discontinue funding a cancer drug when there is another drug available of comparable effectiveness and less cost.’ When asked why they abstained, the participants explained:

Excerpt 7

EMERSON: Basically the way it’s phrased (inaudible) basically redundant.

WYATT: My point exactly. If basically you’re looking for your best bang for your buck and you do this in all areas, I would think that the government would already be doing this, I would assume.

[Inaudible/overlapping speakers]

WYATT: I was looking at like a way to save money, so I don’t see how this isn’t already being practiced in the system already. I think we’re just saying something that’s being done.

FACILITATOR: Is this a helpful recommendation, Marvin, to our policy friends? Is this something that is so, of course they’re doing this.

MARVIN (PI): I’d like to say it was redundant, but it’s not. This is a very helpful recommendation for the policymakers.

FACILITATOR: Does that change your vote at all? It doesn’t have to, it doesn’t have to. Do we want to make one more about the ‘better than’ one or are we still getting pooped out or—

GEORGIA: We’re tired.

Emerson describes the recommendation as ‘basically redundant’ (line 1), and Wyatt agrees: ‘My point exactly’ (line 2). The practice of discontinuing funding is described as an obvious procedure that the government would ‘already’ (used three times) be doing to save money. The obviousness of this procedure is worked up through the descriptions that Wyatt provides, such as ‘I would assume’ (lines 3–4) and ‘you do this in all areas’ (line 3). These phrases work to normalize the practice under question and present it as something that is obviously already being done by policymakers. Together, these descriptions work to present the recommendation as redundant.

When the facilitator asks the PI, Marvin, if this is a useful recommendation, he responds by telling the group that it is. Marvin says: ‘I’d like to say it was redundant, but it’s not. This is a very helpful recommendation for the policymakers’ (lines 10–11). Following this statement, the facilitator asks the participants if they would like to change their votes in light of this new information. This invitation for participants to change their votes works to encourage an open and uncoercive speech environment (Landwehr 2014) and a positive atmosphere (Mansbridge et al. 2006), where participants are encouraged to change their positions in light of new information. Marvin’s declaration that this recommendation is not redundant to policymakers provides a direct counter-argument to Emerson and Wyatt’s reported reasons for abstaining. Despite this, neither of the participants changed their votes in light of this new information.

Abstaining from voting on this recommendation opened a conversation with the PI, Marvin, about whether this statement would be helpful to policymakers. As for previous examples, this action also gave participants an opportunity to have their concerns officially documented in the deliberative outputs.

## Discussion and Conclusion

Recent years have seen a growing interest in methods aimed to engage ordinary citizens in deliberative decision making (Degeling et al. 2016; O’Doherty & Stroud 2019). In 2004, Delli Carpini and colleagues noted that the research on these methods had focused mainly on the theory and practice of deliberative democracy, with few engaged in the work of empirical investigation. In the decades since this observation, there has been an increasing number of empirical investigations of deliberative processes; however, a lot of this work has focused on quantitative pre-post studies. Relatively little attention has been paid to stopping rules and the micro-level interactions between participants and facilitators in the process of forming collective positions. Additionally, this field of inquiry has mostly been ignored by social psychology (O’Doherty & Stroud 2019). In this analysis, we have demonstrated how discursive psychology can be used to explore the social processes that occur during public deliberation events.

This analysis illustrates how deliberative voting can effectively work as a communication tool in public deliberation, as suggested by O’Doherty (2017) and Moore and O’Doherty (2014). The process of deliberative voting can be used to ensure that those whose suggestions did not influence the final recommendation, have an ‘explicit opportunity to express themselves’ (O’Doherty 2017: 11) and have their views officially documented. Through the presented excerpts, we identified how participants in this deliberation used deliberative voting to articulate actual, nuanced, and marginal disagreements with various recommendation statements (Moore & O’Doherty 2014).

The process of documenting minority views provides policymakers with more context and details than the statements and vote tallies would on their own. When the facilitator called on those who had voted against a recommendation or abstained, most participants expressed actual disagreements with the statement. These disagreements may reflect fundamental value differences that persisted despite the participants’ and facilitator’s efforts to find common ground. Documenting actual disagreements alongside the deliberative outputs ensures the preservation of minority views and thus allows policymakers to consider these diverse perspectives in their decision-making. In contrast, nuanced disagreements led to changes in the wording of recommendation statements more often. In these instances, participants articulated issues with the specific wording, scope, or specificity of the statements. Finally, participants infrequently expressed marginal disagreements and did not appear to influence the wording of statements.

In processes that use deliberative voting, the facilitator decides when the process of deliberative voting will begin, and when it ends; thus, ‘[t]he facilitator is both part of the structure within which deliberation is supposed to emerge, and self-evidently a participant in the actual discourse itself’ (Moore 2012: 147). The opportunities that are made available for participants to express disagreement are contingent upon the facilitator’s handling of the event.

To produce a voting process that is both deliberative and iterative, facilitators should take time to encourage dissent, and explore participants’ reasons for disagreement. In the examples discussed here, we showed how the facilitator does this through asking questions, clarifying, validating, seeking more information from PIs and giving deliberants opportunities to change their votes in light of new information. In the final extract we saw how the facilitator invited a PI into the conversation to provide additional context to participants who argued a recommendation was redundant. Once presented with the information that this recommendation was not, in fact, redundant for policymakers, she invited the deliberants to revise their votes. Thus, the facilitator ensures that voting is an iterative process, in which the deliberants are presented with opportunities to change their individual votes, or revise the recommendation statement, in light of new information. This process may provide those participants whose style of communication deviates from the norms of deliberation an explicit opportunity to have their minority positions heard by the group and represented in the deliberative outputs.

Given the important role that organizers and facilitators of deliberative events have in shaping the official conclusions of a deliberative forum, their practice could be enhanced by engaging in reflexive investigation into the ways in which power operates within the structure and practice of deliberation. Blue and Dale (2016) advocate for the integration of reflexive analyses into deliberative practice, including issue framing and facilitation. They write,

Through consistent inquiry into how issues are framed and given meaning in particular institutional settings, deliberative practitioners are better positioned to ask neglected questions about how knowledge and power are wielded in practical settings and how existing power relations might be negotiated so that marginalized perspectives and values are given a fair hearing (Blue & Dale 2016: 16).

The following suggestions may provide guidance for practitioners and facilitators who are interested in engaging in reflexive investigation into how aspects of their practice may influence the process and outcomes of deliberation. First, facilitators should recognize that whom they call on in the reason-giving period will reflect which of the minority views get documented alongside the voting results. Second, practitioners and facilitators alike should be aware of their role in co-producing the outputs of the deliberation. Third, when participants express a disagreement that does not include a direct suggestion for how the wording of the recommendation should be changed, facilitators may find it useful to ask the participant to make an explicit wording suggestion. Finally, facilitators should consider the power and position of event organisers (such as, for example, principal investigators) when they call on them to participate in the conversation. Future research may investigate how facilitators’ social locations, style of communication, and framing of the issues influences the process of deliberative voting and the ultimate outputs of deliberation.

One potential limitation of our study is that the social processes and facilitation described in this analysis are context-specific and cannot be directly transposed onto other deliberating groups. Although the conclusions drawn here may not be directly generalizable to other deliberation events, they may provide helpful information for deliberative practitioners who utilize deliberative voting techniques.

Deliberative voting provides an effective method of identifying collective endpoints of deliberation. We suggest that deliberation facilitators and practitioners should continue to investigate their roles in influencing the collective decisions generated in public engagement forums. In this article, we have used a discursive psychological approach to examine how participants use deliberative voting as a tool to communicate disagreement in a public deliberation event on funding for cancer drugs in Canada. This analysis builds on a small but growing area of research in social psychology on public deliberation. Future research should continue to investigate the social processes taking place within deliberation events.

## Appendix A: Full List of Recommendation Statements

Recommendation Statement Yes No Abstain
1) When we are making recommendations, we take into account some factors. For example, we all agree that prevention is of the utmost importance. 24 0 0
2) We should discontinue funding a cancer drug when there is another drug available of comparable effectiveness and less cost. 21 1 2
3) There should be baseline criteria for funding any drug. 24 0 0
4) Baseline criteria for funding any cancer drug should include moderate improvements to at least one of the following: quality of life, length of life, cost-effectiveness. 20 2 2
5) Approved drugs should be re-reviewed based on post-approval data. 24 0 0
6) The most important criteria to consider when funding cancer drugs is…
Aid quality of life: 19
Length of life: 1
Cost-effectiveness: 0
4
7) Evidence of effectiveness must be based on full disclosure to the regulator of clinical trial sample characteristics, full datasets, and it should be peer reviewed. 23 1 0
8) When considering new drugs, we need to consider the costs and benefits of existing drugs. And if needed, to delist the existing ones and with grandfathering allowed for those people who are still on it. 24 0 0
9) Life extension is valuable, provided there is reasonable quality of life. 23 0 1
10) Processes used to make drug funding decisions should be transparent, so the public understands how decisions are made and who is making them. 23 1 0
11) Trustworthy drug funding decisions should not require patient members on their committees. 9 14 1
12) Trustworthy drug funding decisions should not require members of the general public as participants. 5 18 1
13) The public and public values should play a role in cancer drug funding decisions and this should happen in different ways and at different times. So maybe the public sitting on funding committees, or on citizen panels, for example. 21 1 2
14) How cancer drugs are administered should not restrict whether funding is provided for them, whether that be in the hospital or in the community. 22 2 0
15) Priority should be given to cancer drugs that improve access to treatments where access is poor. 18 6 0
16) There should be a pan-Canadian approach to cancer drug funding decisions, not just funding recommendations. 24 0 0

## Acknowledgements

We thank Dr. Colene Bentley for her administrative support, and Drs. Michael Burgess, Stuart Peacock, and Julia Abelson for inviting us to contribute to this research project. We also thank two anonymous reviewers for insightful and constructive feedback that helped us strengthen the article.

## Funding Information

This research was supported by funding from the Ontario Ministry of Research and Innovation (ER14-10-056).

## Competing Interests

The authors have no competing interests to declare.

## Author Contributions

K.S. led the writing of the manuscript with the support and supervision of K.O. Both authors contributed to all sections of the final manuscript.

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