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Justice and procedure: how does “accountability for reasonableness” result in fair limit-setting decisions?
  1. A Rid
  1. Department of Bioethics, NIH Clinical Center
  2. Institute of Biomedical Ethics, University of Zurich
  1. Dr A Rid, née Shulz-Baldes, Department of Bioethics, National Institutes of Health, Building 10, Room 1C118, Bethesda, MD 20892, USA; schulzbaldesa{at}


Norman Daniels’ theory of justice and health faces a serious practical problem: his theory can ground the special moral importance of health and allows distinguishing just from unjust health inequalities, but it provides little practical guidance for allocating resources when they are especially scarce. Daniels’ solution to this problem is a fair process that he specifies as “accountability for reasonableness”. Daniels claims that accountability for reasonableness makes limit-setting decisions in healthcare not only legitimate, but also fair. This paper assesses the latter claim. Does accountability for reasonableness result in fair limit-setting decisions? It is argued that the answer to this question is not a clear yes. Daniels is remarkably unclear about the criterion of fairness that accountability for reasonableness satisfies. The paper discusses different options for resolving this lack of clarity and examines how they apply to Daniels’ accountability for reasonableness framework. It is concluded, first, that accountability for reasonableness is not a paradigm case of any of the classic notions of procedural justice; second, that what might be called “constrained pure procedural justice” best reflects how accountability for reasonableness results in fair limit-setting decisions; and third, that the procedural conditions of accountability for reasonableness must be further specified and amended to better achieve a fair process, and hence fair limit-setting decisions.

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  • Funding: This work was completed with financial support from the Swiss National Science Foundation.

  • Competing interests: None.

  • The opinions expressed are the author’s own and do not reflect the policies and positions of the National Institutes of Health, the US Public Health Service or the US Department of Health and Human Services.

  • i Thanks to Ben Sachs for suggesting this term.

  • ii I owe the following point to Dave Wendler.

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