Intended for healthcare professionals


Accountability for reasonableness

BMJ 2000; 321 doi: (Published 25 November 2000) Cite this as: BMJ 2000;321:1300

Establishing a fair process for priority setting is easier than agreeing on principles

  1. Norman Daniels, Goldthwaite professor (
  1. Department of Philosophy, Tufts University, Medford MA 02155, USA

    Papers p 1316

    All health systems struggle with the issue of meeting population health needs fairly under resource constraints. Decisions about the implementation of new technologies provide a useful window into the larger issue, and a paper in this week's journal provides a valuable insight into the elements of decision making that decision makers themselves think important in trying to reach fair decisions on applying new technologies in health care.1

    In mixed systems, like that in the United States, decisions whether to fund new technologies—drugs, devices, procedures—are made both by public agencies, such as the Health Care Financing Administration or the Veterans Administration, and by private indemnity insurers and managed care organisations. In the universal coverage systems of most developed countries such decisions are made by public agencies or authorities. Distrust has grown in all these settings. 2 3 Clinicians, patients, and the public—propelled by the media, the internet, and direct to consumer advertising—often believe these decisions are guided solely by the “bottom line,” not patient welfare. The moral legitimacy of limits and priorities thus involves not just who has moral authority to set them, …

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