The ethical canary: narrow reflective equilibrium as a source of moral justification in healthcare priority-setting

Abstract

Healthcare priority-setting institutions have good reason to want to demonstrate that their decisions are morally justified—and those who contribute to and use the health service have good reason to hope for the same. However, finding a moral basis on which to evaluate healthcare priority-setting is difficult. Substantive approaches are vulnerable to reasonable disagreement about the appropriate grounds for allocating resources, while procedural approaches may be indeterminate and insufficient to ensure a just distribution. In this paper, we set out a complementary, coherence-based approach to the evaluation of healthcare priority-setting. Drawing on Rawls, we argue that an institutional priority-setter’s claim to moral justification can be assessed, in part, based on the extent to which its many normative commitments are mutually supportive and free from dissonance; that is, on the ability to establish narrow reflective equilibrium across the normative content of a priority-setter’s policy and practice. While we do not suggest that the establishment of such equilibrium is sufficient for moral justification, we argue that failure to do so might—like the proverbial canary in the coalmine—act as a generalised warning that something is awry. We offer a theoretical argument in support of this view and briefly outline a practical method for systematically examining coherence across priority-setting policy and practice.

An empirical ethics study of the coherence of NICE technology appraisal policy and its implications for moral justification

“…This 'fitting together' is achieved through the method of reflective equilibrium: a process in which "we start with our existing ethical beliefs about cases and principles, weed out those that are thought to be unreliable, and then adjust the remaining set in order to make it as coherent as possible" [31]. 2 One route to morally evaluating a prioritysetter's actions is therefore to identify its various ethical beliefs and empirically assess the extent to which these 'fit together' to form a stable equilibrium [32].…”

“…But we argue that coherence carries justificatory power and that our confidence in any claim for moral justification should be lessened if substantial dissonance can be shown to persist within a priority-setter's moral system. 4 We therefore propose that the empirical examination of coherence is a useful tool for moral evaluation and that, like the proverbial canary in the coalmine, the inability to fully establish NRE across a priority-setter's policy and practice (or within either one of these domains) might act as a generalised warning that something is awry in a priority-setter's moral system [32].…”