Bioethicists have become very good at arguing for transparency. We encourage institutions to disclose conflicts of interest, explain difficult decisions, communicate uncertainty, and justify ethical trade-offs. These are all necessary, even essential — yet they are not enough.

Transparency helps explain decisions. It does not, by itself, create the relationships required for public trust. Bioethics should therefore move beyond transparency toward a more demanding ethical practice: public enrolment.

Many of the most pressing challenges in contemporary bioethics depend on relationships that extend over years. Public health authorities ask communities to participate in vaccination campaigns, population screening programs, and epidemiological surveillance. Health systems increasingly rely on artificial intelligence to support diagnosis and resource allocation. Researchers ask citizens to contribute health data to improve care for future patients.

In every case, institutions are asking people not simply to accept a decision, but to remain engaged in an ongoing collective project. Transparency alone cannot sustain that engagement.

Explanation does not create a relationship

Being told why a decision was made, even when the explanation is transparent and offered in good faith, does not necessarily make people feel included in the process that produced it. Much of what passes for public engagement remains unidirectional: authorities speak, and the public listens. Feedback, when it is invited, is often symbolic — an opportunity to react rather than to influence outcomes.

A common response is to call for more participation. Yet participation itself is frequently treated as a procedural requirement: hold a consultation, invite comments, convene an advisory panel, and move on. Once the exercise ends, so too does the relationship.

Public trust does not work that way.

Relationships grow, stabilize, or weaken depending on whether the people involved continue to find value in them. Friendships dissolve when they become one-sided. Professional collaborations end when expectations are repeatedly frustrated. Institutions likewise lose legitimacy when citizens no longer believe that their concerns, values, or interests matter.

Public trust follows the same logic. It is not a resource that institutions accumulate once and then draw upon whenever cooperation is needed. It is continually shaped by interactions that either strengthen or weaken the relationship. Institutions earn confidence when they demonstrate, over time, that they remain responsive to the communities they serve. People remain engaged when the relationship continues to feel reciprocal, meaningful, and worth sustaining.

Public enrolment is relational work

Public enrolment is the ongoing ethical work of building and sustaining relationships in which institutions and communities recognize one another as legitimate participants in collective decision-making.

It does not mean persuading people to support a predetermined agenda. Nor does it require that every interest be satisfied or every disagreement resolved. It means creating relationships in which participants can continue to see at least some of their interests and values reflected in the exchange. People need evidence that their participation matters and that it can influence what institutions do.

Public enrolment requires more than explaining final decisions. Institutions must show how decisions were reached, where public perspectives entered the process, and how competing interests were weighed. They must make room for and accept meaningful disagreement, not treat it as failure to be avoided. They must also recognize that policies sometimes need to change when the circumstances, evidence, or relationships supporting them change.

Public enrolment, therefore, depends on reciprocity. Institutions cannot ask the public to trust them while treating citizens as passive recipients of expert judgment. Trusting the public means recognizing people as moral agents capable of understanding reasons, uncertainty, and constraints, even when they disagree with the conclusions of decision-makers.

It also means accepting that distrust may be reasonable. People may have good reasons to distrust institutions when decisions are opaque, exclusionary, poorly explained, or disconnected from their lived experience. The ethical task is not to eliminate distrust through better messaging, but to create institutions and relationships that are worthy of trust.

From defensible decisions to ethical relationships

Public enrolment is important in many domains of public policy.

Vaccination campaigns depend not only on persuasive evidence but on sustained confidence in public health professionals and institutions. Population screening programs require people to believe that benefits, burdens, and follow-up responsibilities are justified and fairly distributed. Epidemiological surveillance depends on citizens’ understanding how data will serve collective purposes and how personal information will be protected. AI in healthcare requires confidence that decisions remain accountable to human values rather than being hidden behind opaque technical systems.

These are not isolated ethical choices. They are ongoing relationships between institutions and the publics they serve. Every decision, consultation, policy revision, and institutional response can strengthen or weaken those relationships.

When trust collapses, the consequences extend beyond a single policy. People may stop following guidance because the process that produced it no longer feels legitimate. Cooperation declines, polarization deepens, and collective initiatives become harder to sustain, even when their goals are broadly shared.

It is tempting in such moments to blame misinformation or public irrationality. But doing so avoids a more important ethical question: have institutions treated the public as partners in collective decision-making, or merely as targets of persuasion?

Bioethics has traditionally understood its public role as helping institutions make ethically defensible decisions and explain them clearly. That remains indispensable. Ethical analysis can articulate the values and interests at stake, clarify trade-offs, expose hidden assumptions, and make difficult choices intelligible to all those involved.

If trust is relational rather than transactional, bioethics cannot stop once a decision has been justified. It must also attend to how relationships between institutions and publics are built, sustained, repaired, and sometimes transformed.

The challenge for bioethics is therefore to improve not only the ethics of decision-making, but also the ethics of relationships.

Transparency helps explain decisions. Public enrolment helps sustain the relationships through which those decisions remain legitimate.

Bryn Williams-Jones, PhD is Professor of bioethics and Director of the Department of Social and Preventive Medicine at the School of Public Health, Université de Montréal