How to allocate scarce medical resources is a touchstone question

September 25, 2007

How to allocate scarce medical resources is a touchstone question with ethical, economic, social and political dimensions. Debates focus on rationally coherent and justifiable procedures for prioritizing health-care. Norman Daniels (1985) provided a useful non-utilitarian ethical principle for distributing health care resources which he later developed with James Sabin into a theory of “accountability for reasonableness” (A4R) (Daniels and Sabin 2002). University of Toronto Political Science professors David A. Welsh and Melissa Williams, wrote an Op-Ed (2002) for the Globe and Mail in response to the Canadian Romanow report on health care. They described how a just health-care system through the Rawls lens would be one that works to the greatest benefit of the least-advantaged member of society.



In 2007 the US c. 9 million children still have no health insurance. In 1997 the US government introduced a bipartisan program called S-CHIP broadly supported by both Democrats and Republicans which expanded health coverage to millions of at-risk children from low income families. Private insurance companies like Medicare Advantage, backed by the CATO Institute, are lobbying Senators to minimize the access of vulnerable families to health care by equating these social services based on social justice to a step towards socialism and away from the rights of market freedom (Lieberman 2007).


“By every measure, the ten-year-old program–passed during the Clinton Administration as a bipartisan, incremental effort to expand health coverage to millions of poor kids–has been a success. Thanks to S-CHIP, the number of low-income uninsured kids dropped by one-third over the decade, even as the number of uninsured adults went up. Three out of four eligible kids participate, and studies show they receive preventive care and have improved health outcomes and school performance. “It has been the only success story in initiatives to improve healthcare access,” says Cindy Mann, who directs Georgetown University’s Center for Children and Families [. . .] S-CHIP enjoys broad support among Democratic and Republican governors. Its flexibility allows states to tailor their own programs or build on existing Medicaid arrangements to target children typically in families with incomes of up to 200 percent of the federal poverty level[1] (about $41,300 for a family of four this year) [. . .] This summer the House and Senate passed bills reauthorizing S-CHIP, but by mid-September it became clear that the House bill, which added 5 million uninsured kids to the rolls and paid for their coverage partly by cutting government over-payments to Medicare Advantage plans, would lose to the more minimal Senate approach. Giving health insurance to more kids instead of overpaying highly profitable insurance companies seemed like a good trade. But the Senate, lobbied all year by the insurance industry, didn’t see it that way [. . .] Influential GOP senators, targeted by sellers of Medicare Advantage plans heavily marketed in rural areas, are adamantly against cuts to Medicare Advantage [. . .] Nearly 9 million kids now have no health insurance, and up to two-thirds of them are eligible for S-CHIP or Medicaid. Even so, for [. . .] the White House, both bills cover too many children. [. . .] Apparently the Administration prefers to unleash families into the Darwinian jungle of the private insurance market, where only the wealthiest and healthiest can buy a policy. [. . .] The price for family coverage now averages $12,000, or about 20 percent of income for a family of four with income at 300 percent of the poverty level. [There are] new bare-bones policies, such as the one sold in Ohio by Anthem Blue Cross and Blue Shield with deductibles ranging from $4,000 to $20,000 ($8,000 to $40,000 if the family uses out-of-network providers). The policy covers only two doctor visits per year, and families must pay 30 percent of any hospital bill after satisfying the deductible [. . .] The Cato Institute held a briefing called “Sinking S-CHIP: A First Step Toward Stopping the Growth of Government Health Programs.” Heritage and the American Legislative Exchange Council called their briefing “S-CHIP Expansion: Bad for Kids, Families, and Taxpayers.” They are equating health-care for poor kids with socialism. If that’s the case, our children will be the first casualties on the way to marketplace perfection (Lieberman 2007).”


University of Toronto Political Science professors David A. Welsh and Melissa Williams, wrote this Op-Ed (2002) for the Globe and Mail in response to the Canadian Romanow report on health care. They described how a just health-care system through the Rawls lens would be one that works to the greatest benefit of the least-advantaged member of society:



John Rawls, one of the most important political philosophers of the 20th century, died last week near Boston. We both had the pleasure of studying under him in graduate school, where we came to know him not only as a brilliant thinker, but as a kind and gentle man. He will be sorely missed. Last week Roy Romanow released his much-awaited report on the Canadian health-care system. As proponents and critics predictably squared off, we naturally wondered what Mr. Rawls might have to say about it. Quite a lot, we suspect. And his particular take on the matter would have productively re-framed what is becoming a tiresomely clichéd debate. Part of what made him such a decent human being was his unyielding commitment both to liberty and to equality. What made him a brilliant philosopher is that he had far more success than most in reconciling the two. In his greatest work, A Theory of Justice (1971), he argued that if we understand society as a scheme of co-operation for mutual advantage, we can best accommodate the demands of liberty and equality by designing social institutions around two core principles. The first is that every member of society should be entitled to the fullest scheme of personal liberty consistent with a like liberty for all. The second, or “Difference Principle,” is that inequalities in the distribution of primary goods (things it is rational to want no matter what your particular life plan or conception of the good might be — such as wealth) should work to the greatest benefit of the least-advantaged member of society. It is perfectly all right to have rich people and poor people in society, according to Mr. Rawls, as long as the poorest would be even poorer under any alternative set of basic principles of social distribution. Advocates of private health-care provision stress the importance of liberty — of the right to choose how and where to spend one’s health-care dollar. Advocates of universal public health care stress the importance of equality, of every citizen’s right to the same quality of health care at the same speed of delivery. Mr. Rawls would argue that access to health care is a quintessential primary good: No matter what your life plan might be, it’s rational for you to want it. It’s a limited resource in all societies, and all societies must decide how to distribute it. Some choose market mechanisms; others socialize it. As a primary good, he’d argue, it should be governed by the Difference Principle. A just health-care system is one that works to the greatest benefit of the least-advantaged member of society. Which model would we choose if guided by Rawlsian principles? Existing systems in countries comparably wealthy to Canada offer us clues. From the perspective of the least-well-off, largely private systems such as the American one fare poorly in comparison to public systems such as Canada‘s (though they have advantages such as speed of delivery for costly cutting-edge procedures). But this casual comparison is insufficient. It’s possible that some creative blend of public and private health care might serve the worst-off in society better than does Canada‘s current system, even if revamped in the way suggested by the Romanow report. Mr. Rawls would ask us to think imaginatively about alternatives, model them intensively, and choose accordingly. He would have us embrace whatever worked to the benefit of the least-advantaged — perhaps some creative blend of public and private. Without scrutinizing the alternatives from the perspective of the least-well-off, he’d say, we cannot know whether inequalities in access to health care would be just or unjust. That strikes us as a perspective well worth pondering. Melissa Williams and David Welch teach political science at the University of Toronto (Williams and Welch 2002).



Emanuel ‘s review of Daniels and Sabin’s Setting Limits Fairly – Can We Learn to Share Medical Resources? summarizes the strengths and weaknesses in this widely cited theory of “accountability for reasonableness” (A4R).

“In 1985, Norman Daniels published Just Health Care, which articulated the first useful, nonutilitarian ethical principle for distributing health care resources. Daniels claimed that health care was important because it helped to ensure “normal human functioning,” which in turn enhances people’s opportunities to pursue their life plans. In Daniels’s view, a just health care system tries “to make sure that individuals maintain normal functioning, where possible” — an ethically valuable way to ensure equality of opportunity. Although Daniels’s fair-opportunity principle was an important advance, it became clear that it had problems. First, it appeared to justify the provision of almost all available health care services, since almost everything physicians can do is aimed at maintaining normal functioning and enhancing people’s opportunities. In this sense, it hardly seemed to be a way to set priorities; rather, it seemed to be a way to justify doing nearly everything medically possible. To his credit, Daniels was among the most perceptive critics of his own principle and identified other limitations, such as its inadequacy for helping to determine whether priority should be given to lifesaving interventions for a few patients or to services that improve the quality of life for many. In this new book, Daniels and James E. Sabin offer another approach. They argue that in Western democracies, there is no agreement on substantive principles for the distribution of health care services. Consequently, the challenge is to define the conditions under which it is ethically acceptable for institutions to set limits on health care. They propose four conditions, collectively termed “accountability for reasonableness”: first, publicity (decisions to limit health care and their rationales must be publicly accessible); second, relevance (the rationales invoked must be based on evidence, reasons, and principles that fair-minded persons would affirm); third, appeals (mechanisms for challenging allocation decisions must exist); and fourth, regulation (public procedures must ensure the fulfillment of these three conditions). Daniels and Sabin believe that requiring the use of public, explicit decisions “will improve the quality of decisions making” and will improve public confidence that decisions are made for ethical and not self-interested reasons. Daniels and Sabin devote the second half of their book to studies of how accountability for reasonableness works in the real world. They examine approaches to last-chance therapies, ways in which various managed-care organizations have confronted lung-volume-reduction surgery, and the problems of pharmacy benefit design. One conclusion of Setting Limits Fairly is that, because of limited resources and nonmedical priorities, justice does not entitle people to all effective medical services. Another is that justice does not entitle every person to the same set of medical services. Different health care plans might well come to different determinations, for example, about whether to cover the cost of an artificial heart or the latest migraine medication. Consequently, one person might be entitled to an artificial heart, but his or her neighbor might not be. Yet if the plans’ procedures for determining these distributions fulfill the conditions of accountability for reasonableness, both determinations might be ethical. People are entitled not to the same set of services but, rather, to determinations made through fair procedures. Daniels and Sabin note that agreement on substantive principles for allocating medical resources is unlikely; defining fair procedures for priority setting should be the goal. What is at issue is whether accountability for reasonableness is the right approach. In my opinion, this approach is too passive. Powerful health care institutions make the decisions and provide the reasons, and persons subjected to the decisions merely have the right of appeal. There are, however, avenues for influencing the distribution of resources, such as participation in debates about funding priorities, communication with political representatives, and formation of political associations to lobby and advocate. Fair procedures require the empowerment of those who must live with the medical services that are covered. To augment Daniels and Sabin’s four principles, we need at least three additional principles: first, fair consideration (there must be mechanisms to assess and incorporate every person’s interests and preferences); second, empowerment (there must be mechanisms for persons to influence decision makers and to participate in the decision-making process); and third, impartiality (those formulating and implementing decisions about resource allocation should not have a conflict of interest). In the next decade, every country will face very hard choices about how to allocate scarce medical resources. There is no consensus about what substantive principles should be used to establish priorities for allocations. Instead, we will need fair procedures. Debate will focus on what those procedures should be. Daniels and Sabin’s accountability for reasonableness and illuminating case studies will be invaluable in furthering that debate (Emanuel 2002).”

Schlander expert evidence presented (2007) to the UK House of Commons committee clearly outlines the components of Daniels and Sabin’s concept of Accountability for Reasonableness (A4R).

5.1 Recognizing both the difficulty of democratic societies to achieve consensus on distributive principles for health care and the need for legitimacy of allocation decisions, Norman Daniels and James Sabin (2002) proposed a framework for institutional decision-making, which they call “accountability for reasonableness” (A4R). In order to narrow the scope of controversy, A4R relies on “fair deliberative procedures that yield a range of acceptable answers” and consists of four conditions. 5.1.1 Publicity, ie, resource allocation decisions must be public, including the grounds for making them. Transparency should open decisions and their rationales for scrutiny by all affected, not just the members of the decision-making group; 5.1.2 Relevance, ie, “the grounds for decisions must be ones that fair-minded people can agree are relevant to meeting health care needs fairly under reasonable resource constraints.” Arguments should rest on scientific evidence, though not necessarily a specific kind of, and appeal to the notion of “fair equality of opportunity.” Although Daniels and Sabin acknowledge that stakeholder participation may improve deliberation about complicated matters, they believe it is neither a necessary nor a sufficient condition of A4R; 5.1.3 Revisions and appeal, ie, there must be an institutional mechanism to engage a broader segment of society in the process, providing those affected by a decision to reopen deliberation, and to offer decision-makers an option to revise funding decisions in light of further arguments. 5.1.4 Enforcement entails some form of regulation to make sure that the first three conditions are met (Schlander 2007).

In 2003 Daniels, Teagarden and Sabin provided a template for the application of accountability for the reasonableness in regards to benefit decisions.

“We propose an ethical template for pharmacy benefits and a fair process for using it. The template delineates four levels of decisions about pharmacy coverage, connecting ethically acceptable types of rationales for limits with decisions made at each level. It provides a framework for organizing ethically relevant reasons for coverage (or the tiered copayments). The process for using the template assures accountability for the reasonableness of benefit decisions. It requires transparency and relevance of rationales for limit setting and revisability of decisions, including through fair procedures for appeals. The template and the process facilitate broader public learning about fair limit setting (Daniels, Teagarden and Sabin 2003).”

Accountability for Reasonableness (A4R): “Norman Daniels’ and James Sabin’s theory of “accountability for reasonableness” (A4R) is a much discussed account of due process for decision-making on health care priority setting.

Central to the theory is the acceptance that people may justifiably disagree on what reasons it is relevant to consider when priorities are made, but that there is a core set of reasons, that all centre on fairness, on which there will be no disagreement. A4R is designed as an institutional decision process which will ensure that only those reasons which everybody will agree are relevant and appropriate form part of decision-making. The argument which we will put forward in this paper questions whether it is a simple matter to delineate the core set of reasons and claims that it is a potential problem in A4R that it does not provide an indication of the exact content of this process.The paper first briefly outlines the content of A4R. It is argued that disagreement on what services should be high priorities cannot be resolved solely with a reference to “due process.” In order to retain consistency over time, decision-makers are required to agree and articulate what reasons qualify as relevant and how conflicting reasons are to be balanced in the course of the process.The second and main part of the paper then considers how the reason of “solidarity” can be handled within the A4R framework, and it is shown that deciding whether solidarity should be admitted to the core set of allowable reasons is not a simple matter (Daniels and Sabin).”

Vulnerability, “the susceptibility to harm, results from an interaction between the resources available to individuals and communities and the life challenges they face. Vulnerability results from developmental problems, personal incapacities, disadvantaged social status, inadequacy of interpersonal networks and supports, degraded neighborhoods and environments, and the complex interactions of these factors over the life course. The priority given to varying vulnerabilities, or their neglect, reflects social values. Vulnerability may arise from individual, community, or larger population challenges and requires different types of policy interventions; from social and economic development of neighborhoods and communities, and educational and income policies, to individual medical interventions (Mechanic and Tanner 2007).”

“The logic of cost-effectiveness, as adopted by NICE and in contrast to traditional cost benefit analysis, does not represent an orthodox application of economic welfare theory [5-9]. The development of the cost-effectiveness framework was, instead, heavily influenced by decision analysts with operations research backgrounds, who were striving to transfer methods used to optimise the efficiency of manufacturing processes to the production of health (Schlander 2007).”

Folksonomies, tags, categories, folders, keywords: vulnerability, vulnerability to social exclusion, public versus private, ethics, accountability for reasonableness, priority setting, resource allocation, fairness, solidarity, at-risk youth, at-risk populations, social capital, distributive justice, fiduciary relationships, professional ethics, prioritisation, healthcare resources, a rationally coherent and broadly justifiable regime for prioritising healthcare, accountability for reasonableness, benefits accountable, reasonable resource constraints, share medical resources, special moral importance, touchstone question, health care limits, market accountability, fair process, managed behavioral health care, coverage decisions,


1. The 2007 Health and Human Services Poverty Guidelines lists the threshold for poverty as 4 persons in a household with a combined income of $20,650.

David Welch is Professor of Political Science and Director of the Trudeau Centre for Peace and Conflict Studies at the University of Toronto.


Melissa S. Williams “is Professor of Political Science and founding Director of the Centre for Ethics at the University of Toronto. She is also Editor of NOMOS, the Yearbook of the American Society for Political and Legal Philosophy. Williams teaches in the history of Western political thought, contemporary democratic theory, feminist theory, American political thought, and ethics in the public sphere. “Williams’s research is predominantly in contemporary democratic theory; it frequently addresses core concepts in political philosophy through the lens of group-structured inequality, social and political marginalization, and cultural and religious diversity. Her first book, Voice, Trust and Memory: Marginalized Groups and the Failings of Liberal Representation (Princeton University Press, 1998), develops a theoretical defense of descriptive representation for historically marginalized groups. It won the Foundations of Political Theory Section’s award for the best first book in political philosophy. More recent work has addressed the relationship between peace and justice in the liberal theory of toleration; conceptions of citizenship in an era of globalization; and justice for indigenous peoples. Williams currently has two book projects under way: Equality, for the Routledge Series on Concepts in Political Philosophy; and Reconstructing Impartiality, which begins from feminist and difference-based critiques of liberal impartiality and seeks to develop an alternative account of “situated” or “contextual” impartiality within law-governed relationships. She has published thirty articles on these and other topics in Political Theory, the Canadian Journal of Political Science, numerous edited volumes, and other international journals. Williams has also co-edited a number of works: Identity, Rights and Constitutional Transformation (1999; with Patrick Hanafin); Political Exclusion and Domination (NOMOS XLVI, 2005, with Stephen Macedo); Humanitarian Intervention (NOMOS XLVII, 2005, with Terry Nardin); Toleration and Its Limits (NOMOS XLVIII, forthcoming, with Jeremy Waldron); and Moral Universalism and Pluralism (NOMOS XLIX, forthcoming, with Henry Richardson). Williams was Visiting Faculty Fellow at the Center for Ethics and the Professions at Harvard University (1996-97), Visiting Professor in the Department of Philosophy at the University of Amsterdam (2000), and Laurance S. Rockefeller Visiting Professor for Distinguished Teaching at the Center for Human Values at Princeton University (2000-2001). A former winner of the Leo Strauss Award for the best doctoral dissertation in political philosophy, she has served APSA as a member of the Leo Strauss Award Committee as well as on the Foundations of Political Thought Section’s First Book Award Committee. She is a regular and active participant in ASPA meetings (APSANET).”

Bibliography and Webliography

APSANET (American Political Science Association) Profile of Melissa S. Williams

Daniels, Norman; Teagarden, J. Russell; Sabin, James E. 2003. “Pharmacy Benefits: an Ethical Template for Pharmacy Benefits.” Health Affairs: the Policy Journal for the Health Sphere. 22:1:125-137.

Daniels, Norman, Sabin, James E. 1997. Limits to health care: fair procedures, democratic deliberation, and the legitimacy problem for insurers. Philosophy and Public Affairs. 26:4: 303-350.

Daniels, Norman, Sabin, James E. 1998. The ethics of accountability in managed care reform. Health Affairs. 17:50-64.

Daniels, Norman, 2001. Justice, health, and healthcare. American Journal of Bioethics . 1:2: 2-16.

Daniels, Norman, Sabin, James E. 2002. Setting Limits Fairly – Can We Learn to Share Medical Resources? Oxford: Oxford University Press.

Hasman, Andreas; Holm, Søren. 2005. “Accountability for Reasonableness: Opening the Black Box of Process.” Health Care Analysis. 13: 4. December:261-273(13).

Lieberman, Trudy. 2007. “Let the CHIPs Fall…” The Nation. September 20: October 8, 2007.

Mechanic, David, Tanner, Jennifer. 2007. “Vulnerable People, Groups, And Populations: Societal View: Definitions & Determinants.” Health Affairs: the Policy Journal for the Health Sphere. 26:5:1220-1230.

Schlander, Michael. 2007. Evidence submitted by the Institute for Innovation; Valuation in Health Care (NICE 18). United Kingdom House of Commons Select Committee on Health. Written Evidence. March 16.

Schlander, Michael. “The use of cost-effectiveness by the National Institute for Health and Clinical Excellence (NICE): No(t yet an) exemplar of a deliberative process.” http://jme.bmj.com/preprint/schlander.pdf



Welch, David A., Williams, Melissa. 2002. “Medicare through the Rawls Lens.” Globe and Mail. Op-Ed. December 3. Temporarily posted at http://docs.google.com/Doc?id=ddp3qxmz_56f423xr

Emanuel, Ezekiel J. 2002. “Review of Daniels and Sabin’s Setting Limits Fairly – Can We Learn to Share Medical Resources? (2002).” The New England Journal of Medicine. September 19.

Flynn-Burhoe, Maureen. 2007. “How to allocate scarce medical resources is a touchstone question with ethical, economic, social and political dimensions.” >> Speechless . September 24.

Flynn-Burhoe, Maureen. 2007. “How to allocate scarce medical resources is a touchstone question with ethical, economic, social and political dimensions.” >> Google Docs . September 24.


2 Responses to “How to allocate scarce medical resources is a touchstone question”

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