This paper is a critique of Norman Daniels' and James Sabin's ‘Accountability for Reasonableness’ framework for making priority-setting decisions in health care in the face of widespread disagreement about values. Accountability for Reasonableness has been rapidly gaining worldwide acceptance, arguably to the point of becoming the dominant paradigm in the field of health policy. The framework attempts to set ground rules for a procedure that ensures that whatever decisions result will be fair, reasonable, and legitimate to the extent that even (...) those who would be adversely affected will have reason to abide by them. I argue that the framework's four conditions are inadequate to this task. While we certainly require a fair and legitimate procedure for making priority setting decisions in health care despite a lack of consensus on relevant ethical and political issues, we must significantly revise the four conditions, and we cannot avoid facing our substantive disagreements head on if we hope to arrive at decisions that would (and should) be acceptable to everyone. I offer two suggestions. First, there is need for greater public involvement in all stages of deliberation. Second, we should give up on the idea that we can simplify the task of democratic deliberation by disallowing particular kinds or reasons and types of reasoning. Reasons of all kinds should be on the table, but then should be judged on their merits, such as consistency, plausibility and explanatory power, without any regard for their alleged sources of authority. (shrink)

In 2008 New Zealand's pharmaceutical management agency, PHARMAC, made its final decision on the funding of trastuzumab (Herceptin) for HER2-positive early stage breast cancer. PHARMAC declined to fund the 12-month Herceptin regimen requested by the drug's manufacturer, funding instead a 9-week treatment regimen. The decision was justified on the grounds that there was insufficient evidence of additional long-term health benefits from the longer treatment course, which, coupled with the high cost of the drug, did not make the 12-month regimen sufficiently (...) cost-effective. This paper examines the criticism of PHARMAC's decision that ultimately led to the government's decision to expand the health budget in order to fund the 12-month regimen. It defends PHARMAC's decision against the charge of unfairness, arguing that for high-cost drugs with limited proven effectiveness it is not unfair to deny funding on grounds of cost-effectiveness, since although some moral priority must be given to helping those with serious diseases like breast cancer, the capacity of such drugs to swamp health care budgets is itself a significant moral issue. It concludes that the decision to expand the health budget to pay for Herceptin exacerbates rather than solves the political and moral problems involved in prioritizing health care resources. (shrink)

BackgroundThis paper investigates the content of Australian policies that address withholding or withdrawing life-sustaining treatment to analyse the guidance they provide to doctors about the allocation of resources.MethodsAll publicly available non-institutional policies on withholding and withdrawing life-sustaining treatment were identified, including codes of conduct and government and professional organization guidelines. The policies that referred to resource allocation were isolated and analysed using qualitative thematic analysis. Eight Australian policies addressed both withholding and withdrawing life-sustaining treatment and resource allocation.ResultsFour resource-related themes were (...) identified: doctors’ ethical duties to consider resource allocation; balancing ethical obligations to patient and society; fair process and transparent resource allocation; and legal guidance on distributive justice as a rationale to limit life-sustaining treatment.ConclusionOf the policies that addressed resource allocation, this review found broad agreement about the existence of doctors’ duties to consider the stewardship of scarce resources in decision-making. However, there was disparity in the guidance about how to reconcile competing duties to patient and society. There is a need to better address the difficult and confronting issue of the role of scarce resources in decisions about life-sustaining treatment. (shrink)