Worked example · one decision, followed through
One ministry, one decision, every part of the definition
A health ministry is deciding whether to buy an AI tool that helps clinicians identify patients who need urgent care. Follow that one decision through every part of the definition.
Read down the ledger. Each row is one part of the definition, what the ministry has to work out, and the question it should carry.
- 1
Inquiry and practicelearning what works, and making it count
For the ministry, inquiry might establish whether the triage tool performs reliably across different patient groups. Practice decides who conducts that evaluation, what evidence the ministry receives, and what result would stop the purchase.
What do we need to learn—and how will that knowledge change what someone does?
- 2
Societieswho gets to decide?
The ministry may have the authority to buy the tool. Clinicians and patients still need ways to influence how it is used: information, accessible channels, and some route through which an objection can change a decision. A meeting alone does not provide that.
Who has authority, who is affected, and how can those affected influence or challenge the decision?
- 3
Should shapewhich possibilities are we making easier?
For the ministry, governing the tool could mean requiring evidence before purchase. It could equally mean investing in the staff needed to evaluate suppliers intelligently in the first place.
Which possibilities are we making easier to pursue—and for whom?
- 4
Incentiveswhat does the environment reward?
The same logic runs inside the ministry. If a department is rewarded only for processing patients faster, it may give too little attention to mistakes, accessibility, or unequal performance. If reporting problems threatens a team’s budget, monitoring may produce reassurance rather than useful evidence.
What makes that promise hold under pressure?
- 5
Institutionswho can act?
For the ministry: who approves the purchase? Who can inspect the evidence? Who investigates a complaint? Who can suspend use?
Who is responsible? And what makes them capable of exercising that responsibility?
- 6
Infrastructureswhat does this depend on, and who controls it?
The ministry might buy a tool that performs well but runs on a proprietary service. Over time, patient records, staff training, and clinical workflows become tied to it, while the supplier controls prices and product changes.
What are we becoming dependent on—and what alternatives will remain?
- 7
Safeguardswhat makes protection real?
Suppose the tool performs poorly for one patient group. Who detects that? Does the evidence trigger further testing, a restriction, or suspension? And who verifies that the response actually happened?
What prevents, detects, limits, or remedies failure—and what happens when it fails?
- 8
Share its benefits broadlywho gains?
So the ministry has to decide what improvement means. Shorter waiting times? Better access? Fewer missed urgent cases? Better working conditions? Which groups should benefit, and what evidence would show that they do?
Who gains, who bears the risks and costs, and what would count as a fair outcome?
- 9
Prevent and address harmtwo verbs, two jobs
Switching off a faulty tool does nothing for the patients it has already misjudged. Addressing harm means responding to the person, and to the arrangement that let it happen.
What harm could this cause, who will notice it, and what happens for the people already affected?
- 10
As today’s choices become tomorrow’s conditionswhy timing matters
At first, the ministry is only choosing whether to buy a tool. Later, it may be choosing whether to renew a service its hospitals have reorganized around. Staff have been trained. Data formats have changed. Older procedures have disappeared. The decision is still reversible in principle. In practice, reversal has become expensive and disruptive.
What are we committing ourselves to, and how difficult will it become to change course?
- 11
Maintain the capacity to change coursegovernance must be able to learn
For the ministry, learning depends on information: performance monitoring, incident reports, complaints, independent evaluation, and records that let investigators understand what happened. An institution cannot respond to consequences it cannot see.
How will we discover that this arrangement is failing—and how will we change it?
What this changes in practice
Before
“Is the model accurate enough?”
One question, about the tool.
After
- A limited pilot, keeping existing clinical capacity
- Evidence of performance across patient groups
- Access to records, and rights to export data
- Independent scrutiny
- Conditions for expansion or suspension
These are illustrative choices, rather than a universal prescription. The ministry is now examining the power it transfers, the dependency it creates, the benefits it expects, and the alternatives it retains.
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