Intended for healthcare professionals


Accountability for reasonableness: an update

BMJ 2008; 337 doi: (Published 09 October 2008) Cite this as: BMJ 2008;337:a1850
  1. Norman Daniels, Mary B Saltonstall professor 1,
  2. James E Sabin, clinical professor of psychiatry, ambulatory care, and prevention2
  1. 1Department of Population and International Health, Harvard School of Public Health, 665 Huntington Avenue, Boston MA 02115, USA
  2. 2Ambulatory Care and Prevention, Harvard Medical School, Boston MA 02215
  1. Correspondence to: N Daniels ndaniels{at}

    Twelve years ago (BMJ 1996;312:1553-4) the BMJ argued that health systems needed to be explicit about rationing and published articles describing different ways of rationing fairly. Here a clinician (doi:10.1136/bmj.a1846), two ethicists, and four health economists (doi:10.1136/bmj.a1872) discuss how their ideas have developed—and been put into practice—since then

    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.

    NICE judgments

    Accountability for reasonableness helped shape thinking about how the National Institute for Health and Clinical Excellence (NICE) should incorporate social value judgments into its …

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