Resource allocation decisions in health care are rife with moral disagreements and a fair, deliberative process is necessary to establish the legitimacy and fairness of such decisions.1 2 3 To hold decision makers accountable for the reasonableness of their decisions, we have argued that the process must be public (fully transparent) about the grounds for its decisions; the decision must rest on reasons that stakeholders can agree are relevant; decisions should be revisable in light of new evidence and arguments; and there should be assurance through enforcement that these conditions (publicity, relevance, and revisability) are met.3 The form such procedures should take depends on the institutional context. The decisions are in any case constrained by more general considerations of justice, such as the requirement that they not be discriminatory.

Health systems with public accountability, such as those of Canada, the United Kingdom, New Zealand, and Sweden, and segments of the US system like Kaiser Permanente and the Veterans Administration, are now explicitly applying this framework of accountability.4 We report here on three efforts to implement the approach.