New Edition of Setting Limits Fairly

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"Setting Limits Fairly: Learning to Share Resources for Health" (Second Edition), written with Norman Daniels, has just been published by Oxford University Press. Norman and I have added a new preface and three new chapters to the first edition (2002).

The central idea in the book is that we lack consensus on principles for allocating resources for health. In the absence of consensus we must develop and rely on a fair decision-making process. Norman and I developed our conception of that process - which we call "accountability for reasonableness" - from ten years of studying decision-making in the U.S., Canada, and the U.K.

The accountability for reasonableness framework identifies four conditions for seeking fairness in health priorities:

Relevance – the rationales for priority setting decisions must be based on reasons (evidence and values) that stakeholders can agree are relevant. Procedurally, having a wide range of stakeholders participate in deliberation ensures that the full range of relevant reasons will be considered.

Publicity – priority setting decisions and their rationales must be publicly accessible, not just on demand, but through various forms of active communication outreach.

Revisability – there must be processes for revising decisions and policies in response to new evidence, individual considerations, and public reactions.

Enforcement – local systems and leaders must ensure that the above three conditions are met.

In the six years since the first edition was published, "Setting Limits Fairly" has had more attention outside than inside the U.S. The fragmented U.S. health care system lets us Yanks avoid acknowledging the need for limits. By contrast, universal coverage and fiscal responsibility for health care have forced European and Commonwealth countries to grapple with limits much more directly. A new chapter describes how accountability for reasonableness has been applied in Canada, New Zealand, Sweden, and the U.K. A second new chapter argues that the concepts are relevant for low and middle income countries as well. The final new chapter applies the accountability for reasonableness framework to the effort to eliminate health inequalitites and to advancing the concept of health as a human right.

Books take longer to gestate than even baby elephants do. This blog represents my effort to put ideas about how health organizations and the health system can be more ethical out in real time, and to join forces with others who look at health and health care in a similar spirit.