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Legitimacy in bioethics: challenging the orthodoxy
  1. William R Smith1,2
  1. 1 School of Medicine, Emory University, Decatur, Georgia, USA
  2. 2 Department of Philosophy, University of Notre Dame, Notre Dame, Indiana, USA
  1. Correspondence to William R Smith, School of Medicine, Emory University, Decatur GA 30033, USA; wsmithv{at}


Several prominent writers including Norman Daniels, James Sabin, Amy Gutmann, Dennis Thompson and Leonard Fleck advance a view of legitimacy according to which, roughly, policies are legitimate if and only if they result from democratic deliberation, which employs only public reasons that are publicised to stakeholders. Yet, the process described by this view contrasts with the actual processes involved in creating the Affordable Care Act (ACA) and in attempting to pass the Health Securities Act (HSA). Since the ACA seems to be legitimate, as the HSA would have been had it passed, there seem to be counterexamples to this view. In this essay, I clarify the concept of legitimacy as employed in bioethics discourse. I then use that clarification to develop these examples into a criticism of the orthodox view–that it implies that legitimacy requires counterintuitively large sacrifices of justice in cases where important advancement of healthcare rights depends on violations of publicity. Finally, I reply to three responses to this challenge: (1) that some revision to the orthodox view salvages its core commitments, (2) that its views of publicity and substantive considerations do not have the implications that I claim and (3) that arguments for it are strong enough to support even counterintuitive results. My arguments suggest a greater role for substantive considerations than the orthodox view allows.

  • Political Philosophy
  • Resource Allocation
  • Distributive Justice
  • Public Health Ethics
  • Philosophical Ethics

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  • Contributors WRS is the sole contributor to this piece.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Correction notice This article has been corrected since it published Online First. Multiple changes were made throughout the text to improve wording.