What we Really Owe to Each Other in the Protection of Health: Beyond Accountability for Reasonableness
Norman Daniels’s theory of ‘accountability for reasonableness’ is a hugely influential conception of fairness and legitimacy in the distribution of resources for health. Daniels’s reflections on justice and health are animated by the goal of extending John Rawls’s theory of justice so as to include the value of protecting and promoting health. In fact, a Rawlsian-like principle of opportunity accounts for the value of health, and fair and legitimate decisions are defined in a way that is reminiscent of Rawls’s pure procedural justice. This paper provides a critique of accountability for reasonableness which is internal to the Rawlsian framework. The focus is on two compelling aspects of Rawls’s general approach to justice: the project to find a superior alternative to utilitarianism and intuitionism, and a basic commitment to contractualism. I argue that these aspects are either overlooked or left underdeveloped by Daniels, leading to a theory of justice and health that, besides being unable to differentiate itself from problematic alternatives, rests on uncertain foundations. In fact, Rawls’s powerful critique of utilitarianism and intuitionism has great appeal in the field of justice and health, and a strong social contract element is needed to make the pure procedural aspect of accountability for reasonableness work. The two aspects of Rawls’s theory that should be imported into the field of justice and health are closely connected. This enables me to show how developing the more basic of the two (i.e. a contractualist idea of justification) promises to be of great help in realising the other one (i.e. the need to distance one’s theory of justice and health from utilitarianism and intuitionism).