Setting Limits Fairly: Can We Learn to Share Medical Resources? (review)

Health care systems will increasingly face the problem of how to prioritize interventions with proven benefits. Even affluent countries, faced with situations of moderate scarcity, cannot provide everybody with every medically beneficial intervention, although this is still not generally recognized and accepted. The inevitability of rationing is, of course, even a more pressing concern in low-income countries that typically spend ten to fifteen dollars per capita per year for health care.

For a while there was a simple solution to the problem of resource allocation: allocate resources to that set of interventions that will produce the highest average population health. Many have rightly pointed out that this cannot be the only relevant criterion: there are distributional concerns and there are concerns about treating those who are "worst off" in one sense or another. If one focuses exclusively on maximizing population health, one might choose interventions that provide a very small and trivial benefit to many people rather than a substantial benefit to the more needy. Norman Daniels, one of the authors of this book, has been one of the major contributors to the international debate on the development of a more appropriate moral framework for resource allocation decisions than that of a simple maximizing approach.

In this book, Daniels and Sabin argue forcefully that continuing to try to develop the correct set of substantive principles with the appropriate weights will not contribute much to solving the problem of resource allocation. The simple reason for this is that there is little chance that we will ever develop a consensus on what the proper balance is between competing principles. Therefore, "we must develop an acceptable fair process for setting limits and learn how to apply that process in real-world situations" (10). The book attempts to provide us with a framework for such a procedure and show us how to apply it in selected cases.

The fair process should fulfill four necessary conditions: (1) decisions and the grounds for making them must be public, (2) the grounds for decisions must be of a type that fair-minded people can agree on are relevant, (3) the decisions must be subject to revision and appeal, and (4) the whole procedure must be governed by some type of regulation. Daniels and Sabin are surely right that these are necessary conditions for any fair process, but it is equally clear that we need additional conditions in order to restrict the types of processes that would be allowed under this framework. The following, obviously unfair, procedure would in fact be allowed by Daniels and Sabin: a national law that only allows reimbursement for treatment of people over 65, with an appeal board composed only of people over 65, on the grounds that older people are a disadvantaged group in that particular society.

Some previous attempts to specify fair processes have emphasized input of community or patient representatives as the main mechanism to ensure accountability. Sabin and Daniels rightly reject this approach. Whoever is chosen to be on a decision-making body cannot be said to represent anyone except him or herself. Therefore, one should instead focus one's attention on ensuring that the reasons for a particular decision are public so that they can be scrutinized and criticized in open democratic processes. This approach will ensure much more effective input and influence by the general public on resource allocation decisions. Much work, of course, remains to be done in terms of specifying exactly how decision-making bodies should incorporate public criticism into the appeal process.

Arguably the more interesting and important part of this book is the detailed examination of cases and the demonstration of how Daniels and Sabin's notion of making decision makers "accountable for the reasonableness of their decisions" can be applied...