Health democracy, as a vehicle for citizen participation and a counterweight to medical paternalism, is confronted with two dynamics: the rise of health and scientific populisms, marked by distrust of expertise, and the temptation of an epistocratic mode of governance. These dynamics threaten both scientific authority and democratic legitimacy.

This article poses the following research question: how can health democracy respond simultaneously to the rise of health populisms and to the temptation of epistocratic governance, without compromising either scientific authority or democratic legitimacy?

The study combines a qualitative review of multidisciplinary literature guided by the PRISMA method (PubMed, Google Scholar, Medline; 2015–2025; articles included in the review, n = 31), focusing in particular on vaccination policies and One Health/global health governance, with a theoretical analysis drawing on political philosophy, public health ethics, and the social sciences. The theoretical analysis applies Habermasian communicative rationality as an interpretative framework for assessing governance models.

While health democracy has challenged medical paternalism, it can be instrumentalized by populist dynamics that politicize scientific knowledge and erode institutional trust. Key empirical cases—notably vaccine hesitancy in response to Covid-19 in Europe, the dismantling by the Bolsonaro government of environmental protections in the Amazon, the United States’ withdrawal from the WHO, and the consequences of Brexit for health cooperation—illustrate how populist governments undermine evidence-based public health policies. Conversely, expert-led governance, as observed during Covid-19, can marginalize citizens and restrict democratic processes, constituting what we term an “epistocratic temptation.” We introduce the neologism oligo-epistocracy to describe the concentration of decision-making power within a limited number of domains of scientific expertise within the sciences themselves. The joint examination of populism and epistocracy highlights the structural limits of both models.

The originality of the article lies in its combined analysis of populism and the epistocratic temptation. We argue that a Habermasian deliberative ethics provides a framework capable of regulating asymmetries of knowledge while preserving democratic legitimacy. We also address its limitations, notably power asymmetries and the risk of excluding marginalized voices.

By structuring participation through informed and inclusive deliberation, deliberative ethics mitigates populist distortions, prevents epistocratic drift, strengthens health literacy, and enhances the legitimacy of public health decision-making.