The American Journal of Bioethics

What is the appropriate task of the philosophical ethicist who is concerned with issues about how we ought to ration scarce healthcare resources? Daniels's view, I take it, is that ethical theorists who are concerned with issues of fairness in rationing have, by and large, set themselves the task of articulating "middle-level principles for addressing these rationing problems" (2001). These are conceived of as being formal, all-purpose distributive principles that are meant to provide guidance for the rationing of goods in a wide variety of cases. The principles are "formal" insofar as they are neutral with respect to the good to be rationed; they employ the terminology of benefit, burden, "good," and "goods," but do not speak of specific kinds of goods, or sources of benefit, or grounds for claims of burden. These details are to be filled in on a case-by-case basis.

Though Daniels does not challenge the value of this enterprise, he doubts that there is much hope of a consensus on which principles are the correct principles for the adjudication of rationing problems. Neither principles that direct us to maximize net benefit from the available resources nor principles that tell us to give priority to the worst off in the rationing of resources, appear to be the object of the appropriate kind of consensus on their validity that would be required for either type of principle to claim for itself the mantle of being an authoritative guide to right reasoning about rationing decisions. Daniels, I take it, sees his "accountability for reasonableness" account of how a fair process of reasoning about rationing should proceed as part of a distinct enterprise from that of traditional ethical theorizing, one that has developed in response to the lack of consensus on middle-level distributive principles, with no reason to expect such a consensus to form any time soon.

How one assesses Daniels's claims about the distinctiveness of his approach depends, in part, on whether one accepts his implicit characterization of the aims of ethical theory concerned with the study of fair rationing. One reason for thinking that the articulation of middle-level principles is what philosophers who study the ethics of rationing must be up to is that, methodologically, such a pursuit would be continuous with an easily recognizable "utilitarian" methodological commitment that endorses treating the category of "the good" as a place holder (to be filled in at some later point by one's best account of, e.g., well-being) in one's theorizing about the formal structures of moral reasoning. What is important about this methodological commitment is that it lends credence to the thought that one can productively theorize about how a good should be fairly rationed or distributed, and to the justification for the various benefits and burdens that [End Page 31] might result from such a distribution, independently of questions of what the particular good to be rationed is, orthe particular grounds for the claims of benefit and burden.

A position quite the opposite of this one is, I believe, closer to the truth. Reasoning about how a good is to be fairly rationed or distributed is intimately tied to the character of the good in question and to the reasons for thinking it important to distribute, or make available, that particular good in the first place. There is no reason to think that there are any very general all-purpose principles of fair rationing for philosophers to uncover.

Daniels himself provides a reason for thinking a position of this kind to be plausible. He cites Erik Nord, who finds that most people tend not to have a general commitment to either maximization or maximin as a general approach to rationing cases. Daniels takes this to be evidence of deep disagreement about principles, when it does not in fact count as evidence for any kind of disagreement. On the second position, Nord's results are, in fact, pretty much what one would expect to find. They do not support...