Substance in bureaucratic procedures for healthcare resource allocation: a reply to Smith

Abstract

William Smith's recent article criticises the so-called orthodox approaches to the normative analysis of healthcare resource allocation, associated to the requirement that decision-makers should abide by strictly procedural principles of legitimacy defining a deliberative democratic process. Much of the appeal of Smith's argument goes down to his awareness of real-world processes and, in particular, to the large gap he identifies between well-led democratic deliberation and the messiness of the process through which the intuitively legitimate Affordable Care Act (ACA) was created. This reply aims to demonstrate that the ACA provides no counterexample to orthodox views, seizing this opportunity to explore the specific space that the procedural principles populating orthodox accounts are meant to regulate. Neither general questions of healthcare justice concerning, for example, universal access nor, relatedly, the activity of elected politicians falls within the natural scope of application of such principles, revealing a much more complex picture of the interactions between justice and legitimacy as well as substantive and procedural considerations than acknowledged by Smith. In the end, orthodox accounts of healthcare resource allocation turn out to provide a precious fund of theoretical resources for the normative study of administrators, which might be useful well beyond bioethics and health policy.

Notes on substantance in orthodox theory: a reply to Badano

“…The first is basically the point about the restriction of deliberation to issues not settled by the substantive constraints discussed above. The second is that I neglect orthodox theorists’ emphasis on the ‘regulat[ion of] administrators and … medical staff who … suffer from a legitimacy deficit due, for example, to their not being democratically elected’ 2. The points above clearly show I have not neglected the first.…”

“…First, I assumed an ‘oversimplified version of the orthodoxy’ 2. Second, I failed to appreciate its domain of application 2.…”

“…First, I assumed an ‘oversimplified version of the orthodoxy’ 2. Second, I failed to appreciate its domain of application 2. Third, I only addressed the ways in which orthodox theorists incorporate substance as an ‘afterthought’—and, even then, only by rehashing Gopal Sreenivasan’s argument 2 3…”

“…(Such theorists include Gutmann and Thompson, whom he cites 2as defenders of substantive constraints on deliberation about healthcare 2 4 i ) It is not obvious why such justification is available in the defective deliberative environments that I considered in the earlier paper.…”

“…Of course, Badano points to substantive justifications of healthcare other than appeals to fair equality of opportunity,2 including his own 6iv His justification appeals to a requirement that ‘principles grounding political decisions should be acceptable to each reasonable individual’.…”