ALLOCATING HEALTH-CARE - COST-UTILITY ANALYSIS, INFORMED DEMOCRATIC DECISION-MAKING, OR THE VEIL OF IGNORANCE

Assuming that rationing health care is unavoidable, and that it requir es moral reasoning, how should we allocate limited health care resourc es? This question is difficult because our pluralistic, liberal societ y has no consensus on a conception of distributive justice. In this ar ticle I focus on an alternative: Who shall decide how to ration health care, and how shall this be done to respect autonomy, pluralism, libe ralism, acid fairness? I explore three processes for making rationing decisions: cost-utility analysis, informed democratic decision making, and applications of the veil of ignorance. I evaluate these processes as examples of procedural justice, assuming that there is no outcome considered the most just. I use consent as a criterion to judge compet ing processes so that rationing decisions are, to some extent, self-im posed. I also examine the processes' feasibility in our current health care system. Cost-utility analysis does not meet criteria for actual or presumed consent, even if costs and health-related utility could be measured perfectly. Existing structures of government cannot creditab ly assimilate the information required for sound rationing decisions, and grassroots efforts are not representative. Applications of the vei l of ignorance are more useful for identifying principles relevant to health care rationing than for making concrete rationing decisions. I outline a process of decision making, specifically for health care, th at relies on substantive, selected representation, respects pluralism, liberalism, and deliberative democracy, and could be implemented at t he community or organizational level.