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“Transformative criticism” of epistemic practices and aspirations can also come from global engagement in
decision-making, particularly from the participation of so-called marginalized groups. This can assist in
determining if disagreements between parties are legitimate or the result of competing interests in
contentious situations, such as the ongoing discussion about the redefinition of fatty liver disease.
Democratic control over the consensus-building process can increase the outcome’s credibility for
[16]
widespread adoption . Collective wisdom models frequently make the explicit assumption that
consensus-building arises naturally throughout decision-making processes. Additionally, this procedure
helps guarantee that significant elements that could otherwise go unnoticed are taken into account. As a
result, it may offer the foundation for improved methods of outcome acceptance.

Ultimately, it can bolster the decision’s legitimacy and moral authority. Put another way, deciding what is
equitable for all parties involved requires democratizing the decision-making process. The fairest solutions
typically come from conversations that allow all parties to have a voice in a well-organized process; these
conversations are typically related to the larger question of legitimacy in a democratic, tolerant,
international, and inclusive setting.

HISTORY REPEATS ITSELF: LESSONS CAN BE LEARNED FROM HISTORY TO FUTURE
Initially, it appeared that the debate and reluctance to modify the criteria of fatty liver disease was a
recurrence of a well-known pattern in medical history, where doctors have historically opposed the
increasing impact of data . The advent of randomized clinical trials (RCTs) began as a medical reform
[21]
movement spearheaded by physicians horrified by the detrimental effects of senior physician ego wars and
conflicts across therapeutic schools of thought on patients, particularly the more vulnerable. Resistance and
attempts to stall the introduction of RCTs were encountered by this movement as well. Opinion leaders
asserted that this movement was the product of a collaboration between statisticians and methodologists
[21]
employed by the pharmaceutical industry . RCTs and statistics are becoming commonplace in medical
research and practice.

The so-called “gastric ulcer war” is another glaring illustration. The clinical status quo persisted until 1994
due to the United States' Gastroenterology establishment’s strong rejection of Helicobacter pylori's harmful
role, which was originally discovered in the early 1980s. Notably, those regarded as the authorities on peptic
ulcer illness at the time later characterized this reluctance as the result of cognitive dissonance. Interestingly,
a large number of individuals also affected policy at the National Institutes of Health (NIH) and held
prominent positions at the American Gastroenterology Association (AGA), driven by challenges to their
cosy alliance with the interests of pharmaceutical companies, or the so-called "acid mafia", and their
ongoing NIH grants .
[22]

Another example that history repeats itself occurred with one of the most successful examples of correction
of nomenclature of one liver disease. The argument made at the time was that the term “primary biliary
cholangitis” would cause confusion in clinical practice with other immune-mediated cholangitis types, such
as primary sclerosing cholangitis, and that it would be preferable to maintain the status quo by not changing
the definition of “primary biliary cirrhosis”. As a broad term for an inflammatory illness of the intra- and/or
extra-hepatic bile ducts, “cholangitis” is ambiguous. Remarkably, only roughly 55%-60% of those involved
in the decision-making process supported the switch from “primary biliary cirrhosis” to “primary biliary
cholangitis ”.
[23]

Based on lessons of history, and as a reflection on the current controversy on fatty liver disease redefinition,
how can we ensure that the arguments of those fighting to keep the status quo do not duplicate the same