Les travaux sur la participation n’interrogent presque jamais la question de « l’effet secteur » (au sens de secteur d’action publique) sur la participation, de même que les particularités de la participation liées aux particularités du secteur. De même, ils questionnent peu les effets des pratiques participatives sur les secteurs d’action publique. Tout se passe comme si les secteurs d’action publique étaient interchangeables et réduits à n’être que de simples matériaux empiriques pour questionner la démocratie participative et son instrumentation. Partant de ce constat, cette thèse interroge l’effet sectoriel sur la participation, à travers l’étude de la participation dans le secteur sanitaire. Qu’est-ce que le secteur sanitaire, secteur d’action publique dominé par un haut degré d’expertise et de connaissances scientifiques, politiques et administratives, fait à la participation ? Quelles sont les spécificités de la participation sanitaire ? Pour répondre à ces questionnements, la thèse s’appuie sur une mosaïque de terrains dans l’optique d’avoir une vue suffisamment large et globale du secteur sanitaire, sans être « pris au piège » d’un terrain d’enquête qui serait trop spécifique pour être réellement représentatif du secteur. La thèse interroge à la fois les particularités de la participation sanitaire dans la littérature, à travers la socialisation d’un ensemble d’agents et dans une pluralité de configurations sociales. / Research on participation rarely looks to the impact of the « sector effect » (in the sense of sectors of public activities) on participation or sector-specific particularities in terms of participation. Furthermore, it rarely surveys the effects of participatory practices on different sectors of public activities. Everything happens as though every sector of public activity were interchangeable, with sectors reduced to simple empirical data used to study participatory democracy and how it is instrumentalized. In light of these observations, this dissertation examines the sector effect on participation by studying participation in the healthcare sector. What does the healthcare sector  ̶  an area of public activities dominated by a great degree of expertise and scientific, political, and administrative knowledge  ̶ do to participation? What are the particularities of participation in the healthcare sector? To answer these questions, this dissertation turns to an assortment of fields of inquiry, in order to establish a sufficiently broad and comprehensive overview of the healthcare sector and avoid falling into the “trap” of examining a single field that might be too specific to be truly representative of the sector. This thesis examines the specificities of participation in healthcare in academic research, in the socialization of a variety of people involved in the sector, and in a range of social settings.

In a democracy, what should a healthcare system do? It is a question of relevance to many disciplines. In this thesis, I examine that question, and add something original to the existing debate by drawing on, and synthesizing, thinking from several disciplines, and especially philosophical ethics, economics and systems theory. Paper 6 in this thesis, entitled “In a democracy, what should a healthcare system do?”, tackles the thesis question directly. The central conclusion of that paper, and of this thesis, is that a healthcare system in a democracy should do as much good as possible, although sometimes some overall good should be sacrificed for the sake of fairness, as John Broome has argued. However, what counts as the good of healthcare, and when good should be traded off for fairness, depend on your weltanschauung (or worldview). Political pluralism is normal, and every democracy has institutions and processes for making policy when people disagree because their worldviews differ. Ultimately, elected policymakers are accountable for making decisions. This analysis is complemented by paper 5, entitled “Accountability for reasonableness – as unfair as QALYs?”. It assesses the vulnerability of three theories of resource allocation to injustice. It concludes that Daniels and Sabins’ accountability for reasonableness approach is vulnerable because it does not require evidence of costs and benefits. Maximising quality-adjusted life years can also lead to large-scale injustice because it is concerned only with health gain, and not with fairness. I conclude that a “good and fairness framework”, which is drawn from the writing of John Broome, is the least vulnerable to large-scale injustice. There are four other papers in this thesis. “What has the state got to do with healthcare?” (paper 3) makes the case for an important assumption underpinning this thesis, namely that the question of what a healthcare system should do is a question of public policy. Paper 1, entitled “It’s time for rational rationing” argues that efficiency gains are not inexhaustible, and to continue with its austerity programme, policymakers should assess whether the NHS in England could do more good with the same money by doing different things. I explore how philosophical ethics can contribute to policy, and the importance of context when writing papers about policy, in: “Should policy ethics come in one of two colours: green or white?” (paper 2) and “How can one be both a philosophical ethicist and a democrat?” (paper 4).These latter two papers, and much of the narrative within this thesis, explain how my thinking has developed during the course of my PhD, and why I have looked within and beyond philosophical ethics for an answer to my central research question.